(18) Peds Reds Flashcards
Preterm infants are at risk for
both short-term complications (mainly respiratory and cardiovascular) as well as long-term sequelae (e.g., neurodevelopmental).
Late preterm infants are at
considerable risk for
prematurityrelated
complications
Postterm infants are at increased risk
of
perinatal mortality or morbidity
such as asphyxia and meconium
aspiration
LGA infants may experience difficulties during birth. Infants of mothers with diabetes are often LGA and may have metabolic abnormalities shortly after birth, as well as congenital anomalies
a
A common complication among LGA
newborns is hypoglycemia, which can
result in jitteriness, irritability, cyanosis,
or other health issues
a
While no etiology is noted for many SGA infants, known causes include fetal, placental, and maternal factors. Maternal smoking is associated with SGA newborns
a
Preterm AGA infants are more prone to:
Preterm SGA infants are more likely to
experience:
respiratory distress syndrome, apnea,
patent ductus arteriosus (PDA) with
left-to-right shunt, and infection
asphyxia, hypoglycemia, and hypocalcemia
In breech babies (buttock first), the
knees are flexed in utero; in a frank
breech baby, the knees are extended
in utero. In both, the hips are flexed
a
By 4 days after birth, tremors at rest
signal central nervous system disease
from various possible causes, ranging
from asphyxia to drug withdrawal
a
Asymmetric movements of the arms
or legs at any time suggest central or
peripheral neurologic deficits, birth injury
(such as a fractured clavicle or brachial
plexus injury), or congenital anomalies
a
Newborns who do not demonstrate
these behaviors may have a neurologic
condition, drug withdrawal, or a
serious illness such as infection
a
If you cannot distract the infant or
engage the awake infant with an
object, your face, or a sound, consider
a possible visual or hearing deficit
a
Many neurologic conditions can be diagnosed during this general part of the examination. For example, you can detect hypotonia, conditions associated with irritability or signs of cerebral palsy (see neurologic examination below
a
Observation of the infant’s communication with the parent can reveal abnormalities such as developmental delay, language delay, hearing deficits, or inadequate parental attachment. Likewise, such observations may identify maladaptive nurturing patterns that may stem from maternal depression or inadequate social support.
a
Many disorders cause delays in more than one milestone. For most children with developmental delay, the causes are unknown. Some known causes include abnormality in embryonic development (e.g., prenatal insult); hereditary and genetic disorders (e.g., inborn errors, genetic abnormalities); environmental and social problems (e.g., insufficient stimulation); pregnancy or perinatal problems (e.g., placental insufficiency, prematurity); and childhood diseases (e.g., infection, trauma, chronic illness).
a
If a cooperative infant fails items on a standardized screening instrument, developmental delay is possible, necessitating more precise testing and evaluation.
a
An infant or toddler who has developmental
skills that plateau or are out of
sequence may have autism or cerebral
palsy.
a
As an example, an infant who was born
8 weeks prematurely at 32-week gestation
will have abnormal findings on developmental
screening if expected milestones
are not adjusted for prematurity. At a visit
at 12 months of age, the infant should be
expected to have attained milestones
appropriate for a 10-month old
a
Variations beyond two standard deviations
for age or above the 95th percentile
or below the 5th percentile are
indications for more detailed evaluation.
These deviations may be the first
and only indicators of disease (see
examples on the website tables
a
Although many healthy infants cross percentiles on growth charts, a sudden or significant change in growth may indicate systemic disease due to various possible organ systems or inappropriate excess weight gain usually due to overfeeding
a
Abnormalities that can cause deviation from normal growth patterns include chronic disease or prematurity. Growth charts are also available for children with specific conditions such as Down syndrome or Turner syndrome
a
Reduced growth velocity, shown by a drop in height percentile on a growth curve, may signify a chronic condition. Comparison with normal standards is essential because growth velocity is normally less during the second year than during the first year.
a
Chronic conditions causing reduced length or height include neurologic, renal, cardiac, gastrointestinal, and endocrine disorders as well as cystic fibrosis
a
Failure to thrive is inadequate weight gain for age. Common indicators are: (a) growth <5th percentile for age; (b) drop >2 quartiles in 6 months; or (c) weight for length <5th percentile. Causes include environmental or psychosocial factors and a variety of gastrointestinal, neurologic, cardiac, endocrine, renal, and other diseases.
a
A small head size may result from
premature closure of the sutures or
microcephaly, which may be familial
or due to chromosomal abnormalities,
congenital infections, maternal metabolic disorders, and neurologic insults
An abnormally large head size (>95th
percentile or 2 standard deviations
above the mean) is
macrocephaly which may result from: hydrocephalus, subdural hematoma brain tumor inherited syndromes
Familial megaloencephaly (large head) is a benign familial condition
Causes of sustained hypertension in newborns include renal artery disease (stenosis, thrombosis), congenital renal malformations, and coarctation of the aorta
a
While sinus tachycardia may be extremely rapid, a pulse rate that is too rapid to count (usually >180/min) may indicate paroxysmal supraventricular tachycardia (PSVT
a
Bradycardia may be from drug ingestion,
hypoxia, intracranial or neurologic
conditions, or, rarely, cardiac
dysrhythmia such as heart blockage.
a
Extremely rapid and shallow respiratory
rates are seen in newborns with
cyanotic cardiac disease and right-toleft
shunting, and metabolic acidosis.
a
Fever can raise respiratory rates in
infants by up to 10 respirations per
minute for each degree centigrade
of fever
s
Tachypnea and increased respiratory
effort in an infant are signs of lower
respiratory disease such as bronchiolitis
or pneumonia
a
Fever (>38°C or >100.4°F) in infants younger than age 2 to 3 months may be a sign of serious infection or disease. These infants should be evaluated promptly and thoroughly.
a
Potentially sick febrile infants under 3 months of age may have serious bacterial infection and should have temperatures assessed using a rectal thermometer
a
Anxiety may elevate the body temperature
of children. Excessive bundling of
infants may elevate skin temperature
but not core temperature
a
Temperature instability in a newborn may result from sepsis, metabolic abnormality, or other serious conditions. Older infants rarely manifest temperature instability
a
Some newborns with polycythemia
have a “ruddy” complexion. This is a
reddish purple color
a
Cutis marmorata is prominent in premature infants and in infants with congenital hypothyroidism and Down syndrome. If acrocyanosis does not disappear within 8 hours or with warming, cyanotic congenital heart disease should be considered
a
Central cyanosis in a baby or child of any age should raise suspicion of congenital heart disease. The best area to look for central cyanosis is the tongue and oral mucosa, not the nail beds, lips, or the extremities.
a
Pigmented light-brown lesions (<1 to 2 cm at birth) are café-au-lait spots. Isolated lesions have no significance, but multiple lesions with sharp borders may suggest neurofibromatosis
a
Skin desquamation is normal in fullterm
newborns but may rarely be a
sign of placental circulatory insufficiency
or congenital ichthyosis
a
Both erythema toxicum and pustular
melanosis may appear similar to
the pathologic vesiculopustular rash of herpes simplex or Staphylococcus
aureus skin infection
Midline hair tufts over the lumbosacral
spine region suggest a possible
spinal cord defect
a
Jaundice within the first 24 hours of
birth may be from hemolytic disease of
the newborn
a
Late-appearing jaundice or jaundice
that persists beyond 2 to 3 weeks
should raise suspicions of biliary
obstruction or liver disease
a
A common source of jaundice during the first couple of weeks is breastfeeding jaundice, which resolves around 10 to 14 days of life. Persistent jaundice requires evaluation
a
unilateral dark, purplish lesion, or “port wine stain” over the distribution of the ophthalmic branch of the trigeminal nerve may be a sign of Sturge–Weber syndrome, which is associated with seizures, hemiparesis, glaucoma, and mental retardation
a
Significant edema of the hands and feet of a newborn girl may be suggestive of Turner syndrome. Other features such as a webbed neck would reinforce this diagnosis
a
Dehydration is a common problem in
infants. Usual causes are insufficient
intake or excess loss of fluids from
diarrhea
a
An enlarged posterior fontanelle may be
present in congenital hypothyroidism.
a
Overlap of the cranial bones at the
sutures at birth, called molding, results
from passage of the head through the
birth canal; it disappears within 2 days
a
A bulging, tense fontanelle is observed in infants with increased intracranial pressure, which may be caused by central nervous system infections, neoplastic disease, or hydrocephalus (obstruction of the circulation of cerebrospinal fluid within the ventricles of the brain) (see Table 18-5, Abnormalities of the Head, p. 913
a
Early closure of the fontanelles can be
due to developing microcephaly or to
craniosynostosis or some metabolic
abnormalities
a
Delayed closure of the fontanelles is usually a normal variant, but can be due to hypothyroidism, megalocephaly, increased intracranial pressure, or rickets
a
A depressed anterior fontanelle may
be a sign of dehydration.
a
Dilated scalp veins are indicative of longstanding
increased intracranial pressure
a
A common type of localized swelling of the scalp is a cephalohematoma, caused by subperiosteal hemorrhage from the trauma of birth. This swelling does not cross over suture lines and resolves within 3 weeks. As the hemorrhage resolves and calcifies, there may be a palpable bony rim with a soft center (see Table 18-5, Abnormalities of the Head, p. 913).
a
Plagiocephaly may also reflect pathology such as torticollis from injury to the sternocleidomastoid muscle at birth or lack of stimulation of the infant.
a
Premature closure of cranial sutures causes craniosynostosis (p. 913) and an abnormally shaped skull. Sagittal suture synostosis causes a narrow head from lack of growth of the parietal bones
a
In craniotabes, the cranial bones feel springy. Craniotabes can result from increased intracranial pressure, as with hydrocephaly, metabolic disturbances such as rickets, and infection such as congenital syphilis
a
Micrognathia may also be part of a
syndrome, such as the Pierre Robin
syndrome.
a
Most developmental and genetic
syndromes with abnormal facies also
have other abnormalities
a
An infant with congenital hyperthyroidism may have coarse facial features and other abnormal facial features (Table 18-6, Diagnostic Facies in Infancy and Childhood, pp. 914–915).
a
A child with abnormal shape or length of palpebral fissures (see Table 18-6, Diagnostic Facies in Infancy and Childhood, pp. 914–915): Upslanting (Down syndrome) Downslanting (Noonan syndrome) Short (fetal alcohol effects)
a
A positive Chvostek sign produces facial grimacing caused by repeated contractions of the facial muscles. A Chvostek’s sign is noted in cases of hypocalcemic tetany, tetanus, and tetany due to hyperventilation.
a
A newborn who truly cannot open an
eye (even when awake and alert) may
have:
Causes include:
congenital ptosis
birth trauma
CN III palsy
Subconjunctival hemorrhages are
common in neonates born via vaginal
delivery
a
Nystagmus (wandering or shaking eye movements) persisting after a few days or persisting after the maneuver described on the left may indicate poor vision or central nervous system disease
m
If a newborn fails to gaze at you and follow your face during alert periods, pay particular attention to the rest of the ocular examination. The newborn may have visual impairment from congenital cataracts or other disorders
m
Alternating convergent or divergent strabismus persisting beyond 3 months, or persistent strabismus of any type, may indicate ocular motor weakness or another abnormality in the visual system
m
Colobomas may be seen with the
naked eye and represent defects in
the iris.
m
Brushfield spots (seen with an ophthalmoscope) are a ring of white specks in the iris (see Table 18-7, Abnormalities of the Eyes, Ears, and Mouth, p. 916). Although sometimes present in normal children, these strongly suggest Down syndrome
m
Persistent ocular discharge and tearing
beginning at birth may be from
dacryocystitis or nasolacrimal duct
obstruction
m
Failure to progress along these visual
developmental milestones may indicate
delayed visual maturation
a
Congenital glaucoma may cause cloudiness of the cornea. A dark light reflex can result from cataracts, retinopathy of prematurity, or other disorders. A white retinal reflex (leukokoria) is abnormal, and cataract, retinal detachment, chorioretinitis, or retinoblastoma should be suspected
m
Occlusion of the lens may represent a
cataract
m
Small retinal hemorrhages may occur in normal newborns. Extensive hemorrhages may suggest severe anoxia, subdural hematoma, subarachnoid hemorrhage, or trauma
m
Small, deformed, or low-set auricles
may indicate associated congenital
defects, especially renal disease.
m
Otitis media (see pp. 869–870) can occur in infants.
m
Perinatal problems raising the risk for hearing defects include birth weight <1,500 g, anoxia, treatment with potentially ototoxic medications, congenital infections, severe hyperbilirubinemia, and meningitis
m
In the absence of universal hearing
screening, many children with hearing
deficits are not diagnosed until 2 years.
Clues to hearing deficits include parental
concern about hearing, delayed
speech, and lack of developmental
indicators of hearing.
m
The nasal passages in newborns may be obstructed in choanal atresia. In severe cases, nasal obstruction can be assessed by attempting to pass a no. 8 feeding tube through each nostril into the posterior pharynx. This is usually done in the delivery room to assess for choanal atresia
m
Rarely, supernumerary teeth are noted.
These are usually dysmorphic and are
shed within days but are removed to
prevent aspiration.
pg.827
Although unusual, a prominent, protruding
tongue may signal congenital
hypothyroidism or Down syndrome
a
Oral candidiasis (thrush) is common in infants. The white plaques are difficult to wipe away and have an erythematous raw base (see Table 18-7, Abnormalities of the Eyes, Ears, and Mouth, p. 916). They are found on the buccal mucosa, palate, and tongue.
a
Natal teeth are teeth that are present
at birth. They are usually simply early
eruptions of normal teeth, but they
can be part of syndromes
a
Macroglossia is associated with several systemic conditions. If associated with hypoglycemia and omphalocele, the diagnosis is likely Beckwith–Wiedemann syndrome.
a
A congenital fissure of the median
line of the palate is a cleft palate
a
Inspiratory stridor beginning at birth suggests a congenital abnormality as described in this table. Stridor that appears following birth can be due to infections such as croup, a foreign body, or gastroesophageal reflux
a
Branchial cleft cysts appear as small dimples or openings anterior to the midportion of the sternocleidomastoid muscle. They may be associated with a sinus tract.
a
Preauricular cysts and sinuses are common,
pinhole-size pits, usually located
anterior to the helix of the ear. They
are often bilateral and may be associated
with hearing deficits and renal
disorders
a
Thyroglossal duct cysts are located at the midline of the neck, just above the thyroid cartilage. These small, firm, mobile masses move upward with tongue protrusion or with swallowing. They are usually detected after 2 years
a
Congenital torticollis, or a “wry neck,”
is from
bleeding into the sternocleidomastoid muscle during the stretching process during delivery. A firm fibrous mass is felt within the muscle 2 to 3 weeks after birth and generally disappears over months
A fracture of the clavicle may occur during
birth, particularly during delivery of
a difficult arm or shoulder extraction
a
Two types of chest wall abnormalities
noted in childhood include
pectus excavatum “funnel chest,”
pectus carinatum “chicken breast deformity.”
Apnea is cessation of breathing for more than 20 seconds. It is often accompanied by bradycardia and may indicate respiratory disease, central nervous system disease, or, rarely, a cardiopulmonary condition. Apnea may be a high-risk factor for SIDS
a
In newborns and young infants, nasal flaring may be the result of upper respiratory infections, with subsequent obstruction of their small nares, but it may also be caused by pneumonia or other serious respiratory infections
a
Lower respiratory infections, defined
as infections below the vocal cords,
are common in infants and include
bronchiolitis and pneumonia.
a
Acute stridor is a potentially serious
condition; causes include
laryngotracheobronchitis
(croup), epiglottitis,
bacterial tracheitis, foreign body, hemangioma,
or a vascular ring
In infants, abnormal work of breathing plus abnormal findings on auscultation are the best findings for ruling in pneumonia. The best sign for ruling out pneumonia is the absence of tachypnea
a
Asymmetric chest movement may
indicate a space-occupying lesion
a
Airway obstruction or lower respiratory tract disease in infants can result in the Hoover sign, or paradoxical (seesaw) breathing in which the abdomen moves outward while the chest moves inward during inspiration.
a
Children with muscle weakness may
be noted to have thoracoabdominal
paradox at several years of age.
a
Because of the excellent transmission of sounds throughout the chest, any abnormalities of tactile fremitus or on percussion suggest severe pathology, such as a large pneumonic consolidation.
a
Biphasic sounds imply severe obstruction
from intrathoracic airway narrowing
or severe obstruction from
extrathoracic airway narrowing
a
Diminished breath sounds in one side
of the chest of a newborn suggest
unilateral lesions (e.g., congenital diaphragmatic
hernia or pneumothorax).
a
Upper respiratory infections are not
serious in infants but can produce
loud inspiratory sounds that are often
transmitted to the chest.
a
Wheezes in infants occur commonly from asthma or bronchiolitis. Rhonchi in infants occur with upper respiratory infections. Crackles (rales) can be heard with pneumonia and bronchiolitis.
a
Central cyanosis without acute respiratory symptoms suggests cardiac disease. See Table 18-9, Cyanosis in Children, p. 918, and Table 18-10, Congenital Heart Murmurs, pp. 919–920.
a
In general, cardiac causes of central
cyanosis involve right-to-left shunting
and can be caused by a variety of
congenital cardiac lesions
a
The combination of tachypnea, tachycardia,
and hepatomegaly in infants
suggests heart failure.
A
A diffuse bulge outward of the left
side of the chest suggests longstanding
cardiomegaly
a
A “rolling” heave at the left sternal border suggests an increase in right ventricular work, whereas the same kind of motion closer to the apex suggests the same thing for the left ventricle.
a
PDA is associated with hyperdynamic
precordium and bounding distal
pulses
a
Visible and palpable chest pulsations suggest a hyperdynamic state from either increased metabolic rate or inefficient pumping as a result of an underlying cardiac defect
a
The absence or diminution of femoral pulses is indicative of coarctation of the aorta. If you cannot detect femoral pulses, measure blood pressures of one of the lower and both upper extremities. Normally, the blood pressure in the lower extremity is slightly higher than in the upper extremities. If they are equal or lower in the leg, coarctation is likely to be present.
a
A weak or thready, difficult-to-feel pulse may reflect myocardial dysfunction and heart failure, particularly if associated with an unusual degree of tachycardia
a
Although the pulses in the feet of neonates
and infants are often faint, several
conditions can cause full pulses,
such as PDA or truncus arteriosus
a
The most common abnormal dysrhythmia in infants is paroxysmal atrial tachycardia (PAT). It can occur at any age, including in utero. It is remarkably well tolerated by some infants and children and is found on examination. The child may look perfectly healthy or may be mildly pale or with tachypnea. The heart rate is sustained and regular at around 240 beats per minute or more. Some children, particularly neonates, may appear very ill. In older children, this dysrhythmia is more likely to be truly paroxysmal, with episodes of varying duration and frequency.
a
Distant heart tones suggest pericardial
effusion; mushy, less distinct heart
sounds suggest myocardial dysfunction
a
Pathologic arrhythmias in children can be from structural cardiac lesions but also from other causes such as drug ingestion, metabolic abnormalities, endocrine disorders, serious infections, and postinfectious states, or conduction disturbances without structural heart disease
a
Although ventricular premature contractions
generally occur in otherwise
healthy infants, they can occur with
underlying cardiac disease, particularly
cardiomyopathies and congenital heart
disorders. Electrolyte or metabolic disturbances
are also causes
a
A louder-than-normal pulmonic component,
particularly when louder than
the aortic sound, suggests pulmonary
hypertension
a
Persistent splitting of S2 may indicate a right ventricular volume load such as atrial septal defect, anomalies of pulmonary venous return, or chronic anemia.
a
The third heart sound (S3) should be
differentiated from the higher-intensity
third heart sound gallop, which is a
sign of underlying pathology.
a
Fourth heart sounds (S4), not often
heard in children, are low-frequency,
late diastolic sounds, occurring just
before the first heart sound
a
A true gallop rhythm (in contrast to a widely split S2 which gives an apparent gallop)—tachycardia plus a loud S3, S4, or both—is pathologic and indicates heart failure (poor ventricular function).
a
Any of the noncardiac findings that
frequently accompany cardiac disease
in children markedly raises the possibility
that a murmur is pathologic.
a
Some pathologic murmurs of congenital heart disease are present at birth. Others are not apparent until later, depending on their severity, drop in pulmonary vascular resistance following birth, or changes associated with growth of the child. Table 18-10, Congenital Heart Murmurs, on pp. 919–920, shows examples of pathologic murmurs of childhood.
a
A pulmonary flow murmur in the newborn with other signs of disease is more likely to be pathologic. Diseases may include Williams syndrome, congenital rubella syndrome, and Alagille syndrome
a
A newborn with a heart murmur and
central cyanosis is likely to have congenital
heart disease and requires
urgent cardiac evaluation
a
In premature thelarche, breast development occurs, most often between 6 months and 2 years. Other signs of puberty or hormonal abnormalities are not present
a
A single umbilical artery may be associated
with congenital anomalies or
be an isolated anomaly.
a
An umbilical granuloma at the base of
the navel is the development of pink
granulation tissue formed during the
healing process
a
Infection of the umbilical stump
(omphalitis) can be a serious condition
and is characterized by periumbilical
edema and erythema
839
Umbilical hernias in infants are caused by a defect in the abdominal wall and can be quite protuberant with increased intra-abdominal pressure (i.e., during crying).
a
An increase in pitch or frequency of
bowel sounds is heard with gastroenteritis
or, rarely, with intestinal obstruction
a
A silent, tympanic, distended, and
tender abdomen suggests peritonitis
a
An enlarged, tender liver may be due to heart failure or due to storage diseases. Among newborns, causes of hepatomegaly include hepatitis, storage diseases, vascular congestion, and biliary obstruction
a
Several diseases can cause splenomegaly, including infections, hemolytic anemias, infiltrative disorders, inflammatory or autoimmune diseases, and portal hypertension
a
Abnormal abdominal masses in infants can be associated with the kidney (e.g., hydronephrosis), bladder (e.g., urethral obstruction), bowel (e.g., Hirschsprung disease, or intussusception), and tumors
a
In pyloric stenosis, deep palpation in the
right upper quadrant or midline can
reveal an “olive,” or a 2-cm firm pyloric
mass. While feeding, some infants with
this condition will have visible peristaltic
waves pass across their abdomen,
followed by projectile vomiting. Infants
present at about 4 to 6 weeks of age.
a
Hypospadias refers to an abnormal location of the urethral orifice to some point along the ventral surface of the glans or shaft of the penis (see Table 18-12, The Male Genitourinary System, p. 922). The foreskin is incompletely formed ventrally
a
A fixed, downward bowing of the
penis is a chordee; this may accompany
a hypospadias
s
In newborns with an undescended testicle (cryptorchidism), the scrotum often appears underdeveloped and tight, and palpation reveals an absence of scrotal contents (see Table 18-12, The Male Genitourinary System, p. 922).
a
Two common scrotal masses in newborns are hydroceles and inguinal hernias; frequently both coexist, and both are more common on the right side. Hydroceles overlie the testes and the spermatic cord, are not reducible, and can be transilluminated (Fig. 18-30). Most resolve by 18 months. Hernias are separate from the testes, are usually reducible, and often do not transilluminate. They do not resolve. Sometimes a thickened spermatic cord (called the silk sign) is noted
s
Ambiguous genitalia, involving masculinization of the female external genitalia, is a rare condition caused by endocrine disorders such as congenital adrenal hyperplasia
a
Labial adhesions occur frequently, tend to be paper thin, and often disappear without treatment. The paperthin adhesions attach the labial minora to each other at the midline
a
An imperforate hymen may be noted
at birth
a
A common cause of blood in the stool of
infants is an anal fissure which is a superficial
break in the surface of the anus
and observable with the naked eye.
a
Careful inspection can reveal gross deformities such as dwarfism, congenital abnormalities of the extremities or digits, and annular bands that constrict an extremity
a
Skin tags, remnants of digits, polydactyly
(extra fingers), or syndactyly
(webbed fingers) are congenital
defects noted at birth
a
A fracture of the clavicle can occur
during a difficult birth.
a
Spina bifida occulta (a defect of the vertebral
bodies) may be associated with
defects of the spinal cord, which can
cause severe neurologic dysfunction
a
Developmental dysplasia of the hip
is important to detect as early
treatment has excellent outcomes.
a
A soft audible “click” heard with these
maneuvers does not prove a dislocated
hip, but should prompt a careful
examination.
a
With a developmental dysplasia of the hip, you feel a “clunk” as the femoral head, which lies posterior to the acetabulum, enters the acetabulum. A palpable movement of the femoral head back into place constitutes a positive Ortolani sign
a
A positive Barlow sign is not diagnostic of a dysplastic hip, but indicates laxity and a potentially dislocatable hip. If a Barlow sign is present, the baby needs to be followed very closely. If you feel the head of the femur slipping out onto the posterior lip of the acetabulum, this constitutes a positive Barlow sign. If you feel this dislocation movement, abduct the hip by pressing with your index and middle fingers back inward and feel for the movement of the femoral head as it returns to the hip socket
a
Children older than age 3 months may have a negative Ortolani or Barlow sign and still have a dislocated hip due to tightening of the hip muscles and ligaments. Of note, all babies should receive serial hip examinations until they are walking. In infants beyond 3 months of age, limited abduction is concerning for developmental dysplasia of the hip
a
Severe bowing of the knees can be
normal, but it can also be due to
rickets or Blount disease
- The most common cause of bowing is tibial torsion
Pathologic tibial torsion occurs only in
association with deformities of the feet
or hips
a
True deformities of the feet do not
return to the neutral position even
with manipulation.
a
The most common severe congenital
foot deformity is talipes equinovarus
or clubfoot
a
Signs of severe neurologic disease in infants include extreme irritability, persistent asymmetry of posture, persistent extension of extremities, constant turning of the head to one side, marked extension of the head, neck, and extremities (opisthotonus), severe flaccidity, and limited response to pain, and sometimes seizures
a
Subtle neonatal behaviors such as fine tremors, irritability, and poor selfregulation may indicate withdrawal from nicotine if the mother smoked during pregnancy
a
Persistent irritability in the newborn may be a sign of neurologic insult or may reflect a variety of metabolic, infectious, or other constitutional abnormalities, or environmental conditions such as drug withdrawal
a
Newborns with hypotonia often lie in a frog-leg position, with arms flexed and hands near the ears. Hypotonia can be caused by a variety of central nervous system abnormalities and disorders of the motor unit
a
If changes in facial expression or cry
follow a painful stimulus but no withdrawal
occurs, weakness or paralysis
may be present
a
Abnormalities in the cranial nerves
suggest an intracranial lesion such
as hemorrhage or a congenital
malformation
a
Congenital facial nerve palsy can result
from birth trauma or developmental
defects
a
Dysphagia, or difficulty in swallowing,
can occasionally be due to injury to
cranial nerve IX, X, and XII
a
A progressive increase in deep tendon
reflexes during the first year of life may indicate
central nervous system disease
such as cerebral palsy, especially
if it is coupled with increased tone
Another common pattern of presentation is central hypotonia followed by progressively increased tone
As in adults, asymmetric reflexes
suggest
a lesion of the peripheral nerves or spinal segment
An absent anal reflex suggests loss of innervation of the external sphincter muscle caused by a spinal cord abnormality such as a congenital anomaly (e.g., spina bifida), tumor, or injury
a
When the contractions are continuous
(sustained ankle clonus), central
nervous system disease should be
suspected
a
A newborn who is irritable, jittery and has tremors, hypertonicity, and hyperactive reflexes may have drug withdrawal from maternal substance use during pregnancy
a
Neonatal abstinence syndrome results from the use of opioids by the mother while pregnant. In addition to the signs listed above, the newborn may also have autonomic signs, as well as poor feeding and seizures
a
A neurologic or developmental abnormality is suspected if primitive reflexes are: • Absent at appropriate age • Present longer than normal • Asymmetric • Associated with posturing or twitching
a
Many causes of developmental delay exist but often no cause is identified. Etiologies include prenatal (genetic, central nervous system, congenital hypothyroidism), perinatal (preterm, asphyxia, infection, trauma), and postnatal (trauma, infection, toxin, abuse).
a
Developmental delay across more
than one domain (e.g., motor plus
cognitive) suggests more severe
disease
a
Persistence of palmar grasp reflex
beyond 4 months suggests pyramidal
tract dysfunction
a
Persistence of clenched hand beyond
2 months suggests central nervous
system damage, especially if fingers
overlap the thumb
a
Persistence of plantar grasp reflex
beyond 8 months suggests pyramidal
tract dysfunction.
a
Absence of rooting indicates severe
generalized or central nervous system
disease
a
Persistence beyond 4 months
suggests neurologic disease (e.g.,
cerebral palsy); persistence beyond
6 months strongly suggests it
a
Asymmetric response suggests
fracture of clavicle or humerus or
brachial plexus injury.
a
Persistence beyond 2 months suggests asymmetric central nervous system development and sometimes predicts the development of cerebral palsy.
a
Absence suggests a transverse spinal
cord lesion or injury
850
Persistence may indicate delayed
development
850
Persistence may indicate delayed
development
851
Delay in appearance may predict
future delays in voluntary motor
development
851
Lack of reflex suggests hypotonia or flaccidity. Fixed extension and adduction of legs (scissoring) suggests spasticity from neurologic disease, such as cerebral palsy.
851
Absence of placing may indicate
paralysis.
Newborns born by breech delivery
may not have a placing reflex
851
Short stature, defined as height <5th percentile, can be a normal variant or caused by endocrine or other diseases. Normal variants include familial short stature and constitutional delay. Chronic diseases include growth hormone deficiency, other endocrine diseases, gastrointestinal disease, renal or metabolic disease, and genetic syndromes
s
Young children can have inadequate weight and height gain if caloric intake is insufficient. Etiologies include psychosocial, interactional, gastrointestinal, and endocrine disorders
a
Most children with exogenous obesity
are also tall for their age. Children
with endocrine causes of obesity tend
to be short.
a
Childhood obesity is a major epidemic: 32% of U.S. children have a BMI greater than the 85th percentile, and 17% have a BMI in the 95th percentile or greater.34 Long-term morbidity from childhood obesity spans many organ systems, including cardiovascular, endocrine, renal, musculoskeletal, gastrointestinal, and psychological. Prevention, early detection, and aggressive management are needed
a
A very common cause of apparent hypertension is anxiety or “white-coat hypertension.” The most frequent “cause” of an elevated blood pressure in children is probably an improperly performed examination, often due to an incorrect cuff size
a
In children, as in adults, blood pressure readings from the thigh are approximately 10 mm Hg higher than those from the upper arm. If they are the same or lower, coarctation of the aorta should be suspected
a
Transient hypertension in children can be caused by some common childhood medications, including those to treat asthma (e.g., prednisone) and ADHD (e.g., Ritalin).
a
Causes of sustained hypertension35 in childhood include primary hypertension (with no underlying etiology) and secondary hypertension (which has an underlying etiology). Causes of secondary hypertension include: renal, endocrine, and neurologic disease, vascular causes, drugs or medications and psychological causes. Obesity is highly associated with hypertension in childhood.
a
The epidemic of childhood obesity
has also resulted in a rising prevalence
of childhood hypertension.
a
Sinus bradycardia is a heart rate
<100 beats per minute in infants and
toddlers and <60 beats per minute in
children 3 to 9 years
a
Children with respiratory diseases such as bronchiolitis or pneumonia have rapid respirations (up to 80 to 90/min) and increased work of breathing such as grunting, nasal flaring, or use of accessory muscles
a
Children younger than 3 years, who appear very ill with a fever, should be evaluated for sepsis, urinary tract infection, pneumonia, or other serious infection
a
Fetal alcohol syndrome can cause
abnormal facies
microcephaly
developmental delay
Strabismus (see Table 18-7,
Abnormalities of the Eyes, Ears, and
Mouth, p. 916) in children requires
treatment by an ophthalmologist
a
Both ocular strabismus and anisometropia (eyes with significantly different refractive errors) can result in amblyopia, or reduced vision in an otherwise normal eye. Amblyopia can lead to a “lazy eye,” with permanently reduced visual acuity if not corrected early.
a
The common forms of strabismus in children involve horizontal deviation: nasal (“eso”) or temporal (“exo”). A latent strabismus (“phoria”) occurs when you disrupt fixation, whereas manifest strabismus (“tropia”) is present without interruption.
a
Reduced visual acuity is more likely among children who were born prematurely and among those with other neurologic or developmental disorders.
a
Any difference in visual acuity between the eyes (e.g., 20/20 on the left and 20/30 on the right) is abnormal by age 5 years (Figs. 18-59 and 18-60
a
The most common visual disorder of
childhood is myopia, which can be
easily detected using this examination
technique.
a
Some children develop abnormalities
in near vision, which can lead to reading
difficulties, headaches, and school
problems, as well as double vision
a
With acute mastoiditis, the auricle
may protrude forward and outward,
and the area over the mastoid bone is
red, swollen, and tender
A
Acute otitis media is a common condition of childhood. A symptomatic child typically has a red, bulging tympanic membrane with a dull or absent light reflex and diminished movement on pneumatic otoscopy. Purulent material may also be seen behind the tympanic membrane. See Table 18-7, Abnormalities of the Eyes, Ears, and Mouth, p. 916. The most useful symptom in making the diagnosis is ear pain, if combined with the above signs
a
Sometimes when you are examining acute otitis media leads to a ruptured tympanic membrane, leading to pus in the auditory canal. In these cases, you will generally not visualize the tympanic membrane
a
With otitis externa (but not otitis
media), movement of the pinna elicits
pain.
a
Movement of the tympanic membrane
is absent in middle ear effusion
(otitis media with effusion
a
Significantly, temporary hearing loss
for several months can accompany
otitis media with effusion.
a
Younger children who fail these screening maneuvers or who have speech delay should have audiometric testing. These children may have hearing deficits or central auditory processing disorders
a
Up to 15% of school-aged children
have at least mild hearing loss, emphasizing
the importance of screening for
hearing prior to school age.41
a
The two types of hearing loss seen
in children are conductive and
sensorineural hearing loss.
a
Causes of conductive hearing loss
include congenital abnormalities,
trauma, recurrent otitis media, and
tympanic membrane perforation
a
Causes of sensorineural hearing loss
include hereditary congenital infections,
ototopic drugs, trauma, and
some infections such as meningitis
a
Pale, boggy nasal mucous membranes
are found in children with allergic
rhinitis
a
Purulent rhinitis is common in viral
infections but may be part of the constellation
of symptoms of sinusitis
a
Foul-smelling, purulent, unilateral
discharge from the nose may be due
to a
foreign body
This most often occurs among young preschool children who tend to stick objects into body orifices
Nasal polyps are flesh-colored
growths inside the nares. They are
generally isolated findings, but can
be part of a syndrome.
a
Children with purulent rhinorrhea (generally unilateral) for more than 10 days, and also headache, sore throat, fever, and tenderness over the sinuses may have sinusitis
a
Dental caries are the most common health problem in children. They are particularly prevalent in impoverished populations and can cause both short-term and long-term problems.46 Caries are highly treatable but require a dental visit
a
Dental caries are caused by bacterial activity. Caries are more likely among young children who have prolonged bottle-feeding (“nursing-bottle caries”). See Table 18-8, Abnormalities of the Teeth, Pharynx, and Neck, p. 917, for different stages of caries
a
Staining of the teeth may be intrinsic or extrinsic. Intrinsic stains may be from tetracycline use before 8 years (yellow, gray, or brown stain). Iron preparation (black stain) and fluoride (white stain) are examples of extrinsic stains. Extrinsic stains can be polished off; intrinsic stains cannot (see Table 18-8, Abnormalities of the Teeth, Pharynx, and Neck, p. 917
a
Malocclusion and misalignment of
teeth can be from thumb sucking, a
hereditary condition, or premature
loss of primary teeth
a
Common abnormalities include
coated tongue in viral infections, and
strawberry tongue, from scarlet fever.
a
Children who are severely “tonguetied”
might have a speech impediment
a
A geographic tongue is a benign but
chronic condition in which a portion
of the tongue has a rough, unusual
appearance
a
Streptococcal pharyngitis typically produces a strawberry tongue, white or yellow exudates on the tonsils or posterior pharynx, a beefy-red uvula, and palatal petechiae;
a
A peritonsillar abscess is suggested by
erythema and asymmetric enlargement
of one tonsil, pain, and lateral
displacement of the uvula
a
Acute epiglottitis is now rare in the
United States because of immunization
against Haemophilus influenzae type B.
a
Bacterial tracheitis can cause airway
obstruction
a
Tonsillitis can be caused by bacteria, such as Streptococcus, or viruses. The “rocks in the mouth” voice is accompanied by enlarged tonsils with exudates
a
The epidemic of childhood obesity
has resulted in many children who
snore and have sleep apnea
a
Halitosis in a child can be caused by upper respiratory, pharyngeal, or mouth infection, foreign body in the nose, sinusitis, dental disease, and gastroesophageal reflux
a
Lymphadenopathy is usually from viral
or bacterial infections (see Table 18-8,
Abnormalities of the Teeth, Pharynx,
and Neck, p. 917).
a
Malignancy is more likely if the node is >2 cm, is hard, or is fixed to the skin or underlying tissues (i.e., not mobile) and is accompanied by serious systemic signs such as weight loss.
a
In young children with small necks, it may be difficult to differentiate low posterior cervical lymph nodes from supraclavicular lymph nodes (which are always abnormal and raise suspicion for malignancy).
a
Nuchal rigidity is marked resistance to movement of the head in any direction. It suggests meningeal irritation due to meningitis, bleeding, tumor, or other causes. These children are extremely irritable and difficult to console and may have “paradoxical irritability”—increased irritability when being held.
a
When meningeal irritation is present, the child may assume the tripod position and is unable to assume a full upright position to perform the chin-to-chest maneuver
a
With upper airway obstruction such
as croup, inspiration is prolonged and
accompanied by other signs such as
stridor, cough, or rhonchi
a
With lower airway obstruction such as
asthma, expiration is
prolonged and
often accompanied by wheezing
Pneumonia in young children is generally
manifested by fever, tachypnea, dyspnea,
and increased work of breathing
a
Although upper respiratory infections due to viruses can cause young infants to appear quite ill, in children they present with the same signs as in adults and children generally appear well without lower respiratory signs.
a
Childhood asthma is an extremely common condition throughout the world. Children with acute asthma present with varying severity and often have increased work of breathing. Expiratory wheezing and a prolonged expiratory phase, caused by reversible bronchospasm, may be heard without the stethoscope and are apparent on auscultation. Wheezes are often accompanied by inspiratory rhonchi caused by upper respiratory congestion.49 Asthma flares often occur with viral infections
a
In coarctation of the aorta the blood
pressure is lower in the legs than in
the arms.
a
Among young children, murmurs
without the recognizable features of
the common benign murmurs may
signify
underlying heart disease and
should be evaluated thoroughly by a
pediatric cardiologist
Pathologic murmurs that signify cardiac disease can first appear after infancy and during childhood. Examples include aortic stenosis and mitral valve disease.
a
An exaggerated “pot-belly appearance”
may indicate malabsorption from celiac
disease, cystic fibrosis, or constipation or
aerophagia.
a
A common condition of childhood that can occasionally cause a protuberant abdomen is constipation. The abdomen is often tympanitic on percussion, and stool is sometimes felt on palpation
a
Chronic or recurrent abdominal pain
is relatively common in children.
Causes include both functional
disorders and organic disorders
a
Functional disorders causing abdominal pain include irritable bowel syndrome, functional dyspepsia, and childhood functional abdominal pain syndrome
a
Organic causes of chronic or recurrent abdominal pain in children include gastritis or ulcer, gastroesophageal reflux, constipation, and inflammatory bowel disease
a
Many children present with abdominal pain from acute gastroenteritis. Despite pain, their physical examination is relatively normal except for increased bowel sounds on auscultation and mild tenderness on palpation
a
The childhood obesity epidemic has resulted in many children who have extremely obese abdomens. While it is difficult to accurately examine these children, the steps to the examination are the same as for normal children
a
Hepatomegaly in young children is
unusual. It can be caused by cystic
fibrosis, protein malabsorption, parasites,
fatty liver, and tumors
a
If hepatomegaly is accompanied by
splenomegaly, portal hypertension,
storage diseases, chronic infections,
and malignancy should be considered
a
Various diseases can cause splenomegaly, including infections, hematologic disorders such as hemolytic anemias, infiltrative disorders, and inflammatory or autoimmune diseases, as well as congestion from portal hypertension
a
An abdominal mass felt on
palpation may represent stool from
constipation, or a serious condition
such as a tumor
a
In a child with an acute abdomen, as in
acute appendicitis, check for involuntary
rigidity, rebound tenderness, a Rovsing
sign, or a positive psoas or obturator
sign (see pp. 485–486).51 Gastroenteritis,
constipation, and gastrointestinal
obstruction are other possible etiologies
of acute abdominal pain
a
Precocious puberty is due to excess
androgens and can be caused by multiple
conditions including adrenal or
pituitary tumors
a
Cryptorchidism may be noted at this
age. It requires surgical correction.
It should be differentiated from a
retractile testis
a
Possible causes of a painful testicle
include infection such as epididymitis
or orchitis, torsion of the testicle, or
torsion of the appendix testis
a
A painless scrotal mass in a young boy is usually due to a hydrocele or a nonincarcerated inguinal hernia. Other rare causes include a varicocele or tumor
a
Inguinal hernias in older boys present
as they do in adult men with swelling
in the inguinal canal, particularly
following a Valsalva maneuver
a
The appearance of pubic hair before
age 7 years should be considered
precocious puberty and requires
evaluation to determine the cause
a
Rashes on the external genitals can be from physical irritation, sweating, and candidal or bacterial infections including streptococcal infection
a
Vulvovaginal pruritis and erythema can be caused by external irritants, bubble baths, masturbatory activity, pinworms, or other infections such as Candida or sexually transmitted infections
a
A vaginal discharge in early childhood can be from perineal irritation (e.g., bubble baths or soaps), foreign body, nonspecific vulvovaginitis, Candida, pinworms, or a sexually transmitted infection from sexual abuse
a
Precocious puberty can induce menses
in a young girl
a
Purulent, profuse, malodorous, and
blood-tinged discharge should be
evaluated for the presence of infiltration,
foreign body, or trauma
a
Sexual abuse is unfortunately far too common throughout the world. Up to 25% of women report some history of sexual abuse; while many of these do not involve severe physical trauma, some do.
a
Abrasions or signs of trauma of the external genitalia can be from benign causes such as masturbation, irritants, or accidental trauma, but should also raise the possibility of sexual abuse. See Table 18-11, Physical Signs of Sexual Abuse, p. 932
a
As demonstrated in Table 18-11, Physical Signs of Sexual Abuse, p. 921, physical signs strongly suggestive of sexual abuse include lacerations, ecchymoses and newly healed scars of the hymen, lack of hymenal tissue from 3 to 9 o’clock, and healed hymenal transections. Other signs such as purulent discharge and herpetic lesions are concerning as well
a
Anal skin tags are present in inflammatory
bowel disease but are more
often an incidental finding when
located in the midline
a
Tenderness noted on rectal examination
of a child usually indicates an
infectious or inflammatory cause,
such as an abscess or appendicitis
a
Toddlers may acquire nursemaid’s elbow or subluxation of the radial head from a tugging injury. They will hold their arms slightly flexed at the elbows
a
The cause of acute limp in childhood is
usually trauma or injury, although infection
of the bone, joint, or muscle should
be considered. In an obese child, consider
slipped capital femoral epiphysis
a
Severe bowing of the legs (genu varum) may still be physiologic bowing that will spontaneously resolve. Extreme bowing or unilateral bowing may be from pathologic causes such as rickets or tibia vara (Blount disease
a
The most common lower-extremity pathology in childhood is injury from accidents. Joint injuries, fractures, sprains, strains, and serious ligament injuries such as anterior cruciate ligament tears of the knee are all too common in children
a
A chronic limp in childhood could be caused by Blount disease, hip disorders such as avascular necrosis of the hip, leg length discrepancy, spinal disorder, and serious systemic disease such as leukemia
a
Children with spastic diplegias will often have hypotonia as infants and then excessive tone with spasticity, scissoring, and perhaps clenched fists as toddlers and young children
a
Problems with social interaction, verbal and nonverbal communication,
restricted interests, and repetitive
behaviors could be signs of
autism
In children with uncoordinated gait, be sure to distinguish orthopedic causes such as positional deformities of the hip, knee, or foot from neurologic abnormalities such as cerebral palsy, ataxia, or neuromuscular conditions
a
In certain forms of muscular dystrophy with weakness of the pelvic girdle muscles, children will rise to standing by rolling over prone and pushing off the floor with the arms while the legs remain extended (Gower sign)
a
Children with mild cerebral palsy may
have both slightly increased tone and
hyperreflexia.
a
Distinguish between isolated delays in one aspect of development (e.g., coordination or language) and more generalized delays that occur in several components. The latter is more likely to reflect global neurologic disorders such as cognitive disability that can have many etiologies.
a
Some children with attention deficit disorder
with hyperactivity (ADHD) will have
great difficulty in cooperating with your
neurologic and developmental examination
because of problems focusing. These
children often have high energy levels,
cannot stay still for extended periods,
and have a history of difficulty in school
or structured situations. However, other
conditions may have similar symptoms,
so a complete history and physical examination
is warranted
a
Delayed or disordered development
in early childhood can lead to early
school failure as well as social, behavioral,
and emotional problems
a
Localizing neurologic signs are rare in children but can be caused by trauma, brain tumor, intracranial bleed, or infection. Children with increased intracranial pressure can develop cranial nerve abnormalities as well as papilledema and altered mental status
a
Children with meningitis, encephalitis, or cerebral abscess can have abnormalities of cranial nerves, although they also have altered consciousness and other signs
a
Although facial nerve palsy can be
congenital, it is often caused by
infection or trauma
a
Both obesity and eating disorders (anorexia and bulimia) among adolescent girls are major public health problems requiring regular assessments of weight, monitoring for complications, and promoting healthy choices and self-concept
a
Causes of sustained hypertension for
this age group include primary hypertension,
renal parenchymal disease,
and drug use
a
Adolescent acne, a common skin condition,
tends to resolve eventually,
but often benefits from proper treatment.
It tends to begin during middle
to late puberty
a
Moles or benign nevi may appear during
adolescence. Their characteristics
differentiate them from atypical nevi,
described on p. 912.
a
An adolescent with persistent fever,
tonsillar pharyngitis, and cervical
lymphadenopathy may have infectious
mononucleosis.
a
A pulmonary flow murmur accompanied
by a fixed split second heart
sound suggests right-heart volume
load such as an atrial septal defect
a
Breast buds (pea-size firm masses inferior
to the nipple) are common among
both girls and boys entering puberty
or during early puberty.
a
Breast asymmetry is common in adolescents,
particularly when adolescents
are between Tanner stages 2 and 4. This
is nearly always a benign condition.
a
Many adolescent boys develop gynecomastia (enlarged breasts) on one or both sides. Although usually slight, it can be embarrassingIt generally resolves in a few years
a
Masses or nodules in the breasts of adolescent girls should be examined carefully. They are usually benign fibroadenomas or cysts; less likely, etiologies include abscesses or lipomas. Breast carcinoma is extremely rare in adolescence and nearly always occurs in families with a strong history of the disease
a
Hepatomegaly in teens may be from
infections such as hepatitis or infectious
mononucleosis, inflammatory
bowel disease, or tumors.
a
Delayed puberty is suspected in boys
who have no signs of pubertal development
by 14 years of age.
a
The most common cause of delayed
puberty in males is constitutional delay,
frequently a familial condition involving
delayed bone and physical maturation,
but normal hormonal levels.
a
Although nocturnal or daytime ejaculation tends to begin around Sexual Maturity Rating 3, a finding on either history or physical examination of penile discharge may indicate a sexually transmitted infection
a
In addition to constitutional delay, less common causes of delayed puberty in boys include primary or secondary hypogonadism as well as congenital GnRH deficiency
a
Vaginal discharge in a young adolescent should be treated as in the adult. Causes include physiologic leukorrhea, sexually transmitted infections from consensual sexual activity or sexual abuse, bacterial vaginosis, foreign body, and external irritants.
a
Pubertal development prior to the normal age range may signify
Premature adrenarche is usually benign, but may occasionally be associated with
precocious puberty which has a variety of endocrine and central nervous system causes.
polycystic ovary syndrome, insulin resistance, and metabolic syndrome
Delayed puberty (no breasts or pubic hair development by age 12 years) is usually caused by inadequate gonadotropin secretion from the anterior pituitary due to defective hypothalamic GnRH production. A common cause is anorexia nervosa.
a
Delayed puberty in an adolescent female below the third percentile in height may be from Turner syndrome or chronic disease. The two most common causes of delayed sexual development in an extremely thin adolescent girl are anorexia nervosa and chronic disease
a
Obesity in females can be associated
with early onset of puberty
a
Amenorrhea in adolescence can be primary (no menarche by age 16 years) or secondary (cessation of menses in an adolescent who had previously menstruated). While primary amenorrhea is usually due to anatomic or genetic causes, secondary amenorrhea can be due to a variety of etiologies such as stress, excessive exercise, and eating disorders
a
Several types of scoliosis may present during childhood. Idiopathic scoliosis (75% of cases), seen mostly in girls, is usually detected in early adolescence. As seen in the girl in Figure 18-102, the right hemithorax is generally prominent. Other causes include neuromuscular and congenital
a
Important risk factors for sudden cardiovascular
death during sports
include episodes of dizziness or palpitations,
prior syncope (particularly if associated
with exercise), or family history
of sudden death or cardiomyopathy in
young or middle-aged relatives
a
During the preparticipation sports
physical examination, assess carefully
for
cardiac murmurs and wheezing in
the lungs
Also, if the adolescent has
had head injuries or a concussion, perform a careful, focused neurologic
examination
Common Abnormalities from Prior Injury Step 1: Asymmetry, swelling of joints Step 2: Loss of range of motion Step 3: Weakness of shoulder, neck, or trapezius muscles Step 4: Loss of strength of deltoid muscle Step 5: Loss of external rotation and injury of glenohumeral joint Step 6: Reduced range of motion of elbow Step 7: Reduced range of motion from injury to forearm, elbow, or wrist Step 8: Protruding knuckle, reduced range of motion of fingers from prior sprain or fracture Step 9: Inability to fully flex knees and difficulty standing up from prior knee or ankle injury Step 10: Asymmetry from scoliosis, leg-length discrepancy, or weakness from injury Step 11: Asymmetry from scoliosis and twisting of back from low back pain Step 12: Wasting of calf muscles from ankle or Achilles tendon injury
p 903-4
