(18) Peds Tables Flashcards
Erythema Toxicum
These common yellow or white pustules
are surrounded by a red base.
Neonatal Acne
Red pustules and papules are most
prominent over the cheeks and nose of
some normal newborns.
Seborrhea
The salmon red, scaly eruption often
involves the face, neck, axilla, diaper
area, and behind the ears
Atopic Dermatitis (Eczema)
Erythema, scaling, dry skin, and intense itching characterize this condition.
Neurofibromatosis
Characteristic features include more than
5 café-au-lait spots and axillary freckling.
Later findings include neurofibromas and
Lisch nodules (not shown).
Candidal Diaper Dermatitis
This bright red rash involves the
intertriginous folds, with small “satellite
lesions” along the edges
Contact Diaper Dermatitis
This irritant rash is secondary to diarrhea
or irritation and is noted along contact
areas (here, the area touching the diaper).
Impetigo
This infection is due to bacteria and can
appear bullous or crusty and yellowed
with some pus
Verruca Vulgaris
Dry, rough warts on hands
Verruca Plana
Small, flat warts
Plantar Warts
Tender warts on feet
Molluscum Contagiosum
Dome-shaped, fleshy lesions
Adolescent Acne
Acne in adolescents involves open comedones (blackheads) and closed comedones
(whiteheads) shown at the left, and inflamed pustules (right).
Bites
Intensely pruritic, red, distinct papules
characterize these lesions
Tinea Capitis
Scaling, crusting, and hair loss are seen in
the scalp, along with a painful plaque
(kerion) and occipital lymph node (arrow).
Urticaria (Hives)
This pruritic, allergic sensitivity reaction
changes shape quickly
Scabies
Intensely itchy papules and vesicles,
sometimes burrows, most often on
extremities
Tinea Corporis
This annular lesion has central clearing
and papules along the border.
Pityriasis Rosea
Oval lesions on trunk, in older children, often
in a Christmas tree pattern, sometimes a
herald patch (a large patch that appears first)
Cephalohematoma
Although not present at birth, cephalohematomas appear within the
first 24 hours from subperiosteal hemorrhage involving the outer
table of one of the cranial bones. The swelling, shown at the arrow,
does not extend across a suture though it is occasionally bilateral
following a difficult birth. The swelling is initially soft, then develops
a raised bony margin within a few days from calcium deposits at the
edge of the periosteum. It tends to resolve within several weeks
Hydrocephalus
- the anterior fontanelle is bulging
- the eyes may be deviated downward revealing the upper scleras and creating the setting sun sign (setting sun sign is also seen briefly in some normal newborns)
Craniosynostosis
Craniosynostosis is a condition of premature closure of one or more
sutures of the skull. This results in an abnormal growth and shape of
the skull because growth will occur across sutures that are not
affected but not across sutures that are affected.
The figures demonstrate different skull shapes associated with the
various types of craniosynostosis. The prematurely closed suture line is
noted by the absence of a suture line in each figure. Scaphocephaly and
frontal plagiocephaly are the most common forms of craniosynostosis.
The blue shading shows areas of maximal flattening. The red arrows
show the direction of continued growth across the sutures, which is
normal.
Fetal Alcohol Syndrome
Babies born to women with chronic alcoholism are at increased
risk for growth deficiency, microcephaly, and intellectual
disability. Facial characteristics include short palpebral fissures,
a wide and flattened philtrum (the vertical groove in the
midline of the upper lip), and thin lips
Congenital Hypothyroidism
The child with congenital hypothyroidism (cretinism) has
coarse facial features, a low-set hair line, sparse eyebrows, and
an enlarged tongue. Associated features include a hoarse cry,
umbilical hernia, dry and cold extremities, myxedema,
mottled skin, and intellectual disability. Most infants with
congenital hypothyroidism have no physical stigmata; this has
led to screening of all newborns in the United States and most
other developed countries for congenital hypothyroidism.
Congenital Syphilis
In utero infection by Treponema pallidum usually occurs after
the 16th week of gestation and affects virtually all fetal organs.
If it is not treated, 25% of infected babies die before birth and
another 30% shortly thereafter. Signs of illness appear in
survivors within the first month of life. Facial stigmata often
include bulging of the frontal bones and nasal bridge
depression (saddle nose), both from periostitis; rhinitis from
weeping nasal mucosal lesions (snuffles); and a circumoral rash.
Mucocutaneous inflammation and fissuring of the mouth and
lips (rhagades), not shown here, may also occur as stigmata of
congenital syphilis, as may craniotabes tibial periostitis (saber
shins) and dental dysplasia (Hutchinson teeth—see p. 296).
Facial Nerve Palsy
Peripheral (lower motor neuron) paralysis of the facial nerve
may be from (1) an injury to the nerve from pressure during
labor and birth, (2) inflammation of the middle ear branch of
the nerve during episodes of acute or chronic otitis media, or
(3) unknown causes (Bell palsy). The nasolabial fold on the
affected left side is flattened, and the eye does not close. This
is accentuated during crying, as shown here. Full recovery
occurs in ≥90% of those affected
Down Syndrome
The child with Down syndrome (trisomy 21) usually has a
small, rounded head, a flattened nasal bridge, oblique palpebral
fissures, prominent epicanthal folds, small, low-set, shell-like
ears, and a relatively large tongue. Associated features include
generalized hypotonia, transverse palmar creases (simian lines),
shortening and incurving of the fifth fingers (clinodactyly),
Brushfield spots (see p. 916), and mild to moderate cognitive
impairment.
Battered Child Syndrome
The child who has been physically abused (battered) may
have old and fresh bruises on the head and face. Other stigmata
include bruises in areas (axilla and groin) not usually subject
to injury rather than the bony prominences; x-ray evidence of
fractures of the skull, ribs, and long bones in various stages of
healing; and skin lesions that are morphologically similar to
implements used to inflict trauma (hand, belt buckle, strap,
rope, coat hanger, or lighted cigarette). Of note, while many
normal children have bruises on bony prominences, abused
children are more likely to have bruises on protected areas
Perennial Allergic Rhinitis
The child suffering from perennial allergic rhinitis has an open
mouth (cannot breathe through the nose) and edema and
discoloration of the lower orbitopalpebral grooves (“allergic
shiners”). Such a child is often seen to push the nose upward
and backward with a hand (“allergic salute”) and to grimace
(wrinkle the nose and mouth) to relieve nasal itching and
obstruction.
Hyperthyroidism
Thyrotoxicosis (Graves disease) occurs in approximately 2 per
1,000 children younger than 10 years. Affected children exhibit
tachycardia, hypermetabolism, and accelerated linear growth.
Facial characteristics shown in this 6-year-old girl are “staring”
eyes (not true exophthalmos, which is rare in children) and an
enlarged thyroid gland (goiter).
Brushfield Spots
These abnormal speckling spots on the iris suggest Down
syndrome
Strabismus
Strabismus, or misalignment of the eyes, can lead to visual
impairment. Esotropia, shown here, is an inward deviation.
Otitis Media
Otitis media is one of the most common conditions in young children. The spectrum of otitis media is shown here. A: Typical
acute otitis media with a red, distorted, bulging tympanic membrane in a highly symptomatic child. B: Acute otitis media with
bullae formation and fluid visible behind the tympanic membrane. C: Otitis media with effusion, showing a yellowish fluid
behind a retracted and thickened tympanic membrane. Often you can no longer visualize the normal landmarks such as the
light reflex and handle of the malleus
Oral Candidiasis (“Thrush”)
This infection is common in infants. The white plaques do not
rub off
Herpetic Stomatitis
Tender ulcerations on the oral mucosa are surrounded by
erythema
Dental Caries
Dental caries is a major global health and pediatric
problem. White spots on the teeth often reflect early
caries. The photographs to the left show different
characteristics of caries
Staining of the Teeth
Various causes can lead to staining of the teeth of children, including intrinsic stains
such as tetracycline (left) or extrinsic stains such as poor oral hygiene (not shown).
Extrinsic stains can be removed
Streptococcal Pharyngitis
“Strep Throat”
This common childhood infection has a classic
presentation of erythema of the posterior pharynx
and palatal petechiae. A foul-smelling exudate is
also commonly noted
Lymphadenopathy
Enlarged and tender cervical lymph nodes are common in children. The most likely
causes are viral and bacterial infections. Lymph node enlargement can be bilateral, as
shown in the figure to the left.
Generalized Cyanosis
This baby has total anomalous pulmonary venous return and
an oxygen saturation level of 80%.
It is important to recognize cyanosis:
The best location to examine is the mucous membranes. Cyanosis is a “raspberry” color,
whereas normal mucous membranes should have a “strawberry” color.
Perioral Cyanosis
This baby has mild cyanosis above the lips, but the mucous
membranes remain pink
Bluish Lips, Giving Appearance of Cyanosis
Normal pigment deposition in the vermilion border of the lips
gives them a bluish hue, but the mucous membranes are pink
Acrocyanosis
This commonly appears on the feet and hands of babies
shortly after birth. This infant is a 32-week-old newborn
Pulmonary Valve Stenosis
Usually a normal valve annulus with
fusion of some or most of the valve
leaflets, restricting flow across the valve
Pulmonary Valve Stenosis:
Characteristics of the Murmur
Location. Upper left sternal border Radiation. In mild degrees of stenosis, the murmur may be heard over the course of the pulmonary arteries in the lung fields. Intensity. Increases in intensity and duration as the degree of obstruction increases Quality. Ejection, peaking later in systole as the obstruction increases
Pulmonary Valve Stenosis (kids):
associated findings
Usually a prominent ejection click in early systole Pulmonary component of the second sound at the base (P2) becomes delayed and softer, disappearing as obstruction increases. Inspiration may increase murmur; expiration may increase click. Growth is usually normal. Newborns with severe stenosis may be cyanotic from right-to-left atrial shunting and rapidly develop heart failure as the ductus arteriosus closes
Aortic Valve Stenosis
Usually a bicuspid valve with progressive obstruction, but may occur as a result of a dysplastic valve or damage from rheumatic fever or degenerative disease S1
Aortic Valve Stenosis: characteristics
Location. Midsternum, upper right sternal border Radiation. To the carotid arteries and suprasternal notch; may also be a thrill Intensity. Varies, louder with increasingly severe obstruction Quality. An ejection, often harsh, systolic murmur
Aortic Valve Stenosis: associated findings in kids
May be an associated ejection click The aortic closure sound may be increased in intensity. There may be a diastolic murmur of aortic valve regurgitation (not shown in the diagram). Newborns with severe stenosis may have weak or absent pulses and severe heart failure. May not be audible until adulthood even though the valve is congenitally abnormal
Tetralogy of Fallot
Complex defect with ventricular septal
defect, infundibular and usually valvular
right ventricular outflow obstruction,
malrotation of the aorta, and right-to-left
shunting at ventricular septal level
Tetralogy of Fallot: characteristics
General. Variable cyanosis, increasing with activity Location. Mid-to-upper left sternal border. If pulmonary atresia, the continuous murmur of ductus arteriosus flow at upper left sternal border or in the back. Radiation. Little, to upper left sternal border, occasionally to lung fields Intensity. Usually grade III–IV Quality. Systolic ejection murmur
Tetralogy of Fallot: associated findings in kids
Normal pulses
The pulmonary closure sound is usually
not heard. May have abrupt
hypercyanotic spells with sudden
increase in cyanosis, air hunger, altered
level of awareness
Failure to gain weight with persistent and
increasingly severe cyanosis
Long-term persistence of cyanosis accompanied
by clubbing of fingers and toes
Persistent hypoxemia leads to polycythemia,
which will accentuate the cyanosis.
Transposition of the Great Arteries
A severe defect with failure of rotation of
the great vessels, leaving the aorta to arise
from the right ventricle and the
pulmonary artery from the left ventricle
Transposition of the Great Arteries: characteristics
General. Intense generalized cyanosis Location. No characteristic murmur. If present, it may reflect an associated defect such as ventricular septal defect (VSD). Radiation and Quality. Depends on associated abnormalities
Transposition of the Great Arteries: associated findings in kids
Single loud second sound of the anterior aortic valve Frequent rapid development of heart failure Frequent associated defects as described at the left
Ventricular Septal Defect
Blood going from a high-pressure left ventricle through a defect in the septum to the lower-pressure right ventricle creates turbulence, usually throughout systole.
Ventricular Septal Defect: characteristics
Location. Lower left sternal border Radiation. Little Intensity. Variable, only partially determined by the size of the shunt. Small shunts with a high-pressure gradient may have very loud murmurs. Large defects with elevated pulmonary vascular resistance may have no murmur. Grade II–IV/VI with a thrill if grade IV/VI or higher. Quality. Pansystolic, usually harsh, may obscure S1 and S2 if loud enough
Ventricular Septal Defect: associated findings in kids
With large shunts, there may be a lowpitched middiastolic murmur of relative mitral stenosis at the apex. As pulmonary artery pressure increases, the pulmonic component of the second sounds at the base increases in intensity. When pulmonary artery pressure equals aortic pressure there may be no murmur and P2 will be very loud. In low-volume shunts, growth is normal. In larger shunts, heart failure may occur by 6–8 wks; poor weight gain, poor feeding. Associated defects are frequent.
Patent Ductus Arteriosus
Continuous flow from aorta to
pulmonary artery throughout the cardiac
cycle when ductus arteriosus does not
close after birth
Patent Ductus Arteriosus: characteristics
Location. Upper left sternal border and to left Radiation. Sometimes to the back Intensity. Varies depending on size of the shunt, usually grade II–III/VI. Quality. A rather hollow, sometimes machinery-like murmur that is continuous throughout the cardiac cycle, although occasionally almost inaudible in late diastole, uninterrupted by the heart sounds, louder in systole
Patent Ductus Arteriosus: associated findings in kids
Full to bounding pulses Noticed at birth in the premature infant who may have bounding pulses, a hyperdynamic precordium, and an atypical murmur Noticed later in the full-term infant as pulmonary vascular resistance falls May develop heart failure at 4–6 wks if large shunt Poor weight gain related to size of shunt Pulmonary hypertension affects murmur as above
Atrial Septal Defect
Left-to-right shunt through an opening in
the atrial septum, possible at various levels
Atrial Septal Defect: characteristics
Location. Upper left sternal border Radiation. To the back Intensity. Variable, usually grade II–III/VI Quality. Ejection but without the harsh quality
Atrial Septal Defect: associated findings in kids
Widely split second sounds throughout all phases of respiration, normal intensity Usually not heard until after age of 1 yr Gradual decrease in weight gain as shunt increases Decreased exercise tolerance, subtle, not dramatic Heart failure is rare
Physical Signs of Sexual Abuse: possible indications
- Marked and immediate dilatation of the anus in knee–chest position, with no constipation, stool in the vault, or neurologic
disorders - Hymenal notch or cleft that extends >50% of the inferior hymenal rim (confirmed in knee–chest position)
- Condyloma acuminata in a child older than 3 yrs
- Bruising, abrasions, lacerations, or bite marks of labia or perihymenal tissue
- Herpes of the anogenital area beyond the neonatal period
- Purulent or malodorous vaginal discharge in a young girl (culture and view all discharges under a microscope for evidence of
a sexually transmitted infection)
Physical Signs of Sexual Abuse: strong indications
- Lacerations, ecchymoses, and newly healed scars of the hymen or the posterior fourchette
- No hymenal tissue from 3 o’clock to 9 o’clock (confirmed in various positions)
- Healed hymenal transections especially between 3 and 9 o’clock (complete cleft)
- Perianal lacerations extending to external sphincter
Hypospadias
Hypospadias is the most common congenital penile
abnormality. The urethral meatus opens abnormally on the
ventral surface of the penis. One form is shown above; more
severe forms involve openings on the lower shaft or scrotum
Undescended Testicle
You should distinguish between undescended testes, shown
above, (with testes in the inguinal canals—see arrows), from
highly retractile testes from an active cremasteric reflex
Common Musculoskeletal Findings in Young Kids
- Flat feet or pes planus from laxity of the
soft tissue structures of the foot - Inversion of the foot (varus) - - Metatarsus adductus in a child. The
forefoot is adducted and not inverted - Pronation in a toddler. A: When viewed from behind, the hindfoot is everted. B: When viewed from the front, the forefoot is
everted and abducted
Table 18-14: Vaccine Preventable Diseases
pg. 923
pictures but no real info
