(18) Peds Reds Flashcards
(325 cards)
1
Q
Preterm infants are at risk for
A
both short-term complications (mainly respiratory and cardiovascular) as well as long-term sequelae (e.g., neurodevelopmental).
2
Q
Late preterm infants are at
considerable risk for
A
prematurityrelated
complications
3
Q
Postterm infants are at increased risk
of
A
perinatal mortality or morbidity
such as asphyxia and meconium
aspiration
4
Q
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
5
Q
A common complication among LGA
newborns is hypoglycemia, which can
result in jitteriness, irritability, cyanosis,
or other health issues
A
a
6
Q
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
a
7
Q
Preterm AGA infants are more prone to:
Preterm SGA infants are more likely to
experience:
A
respiratory distress syndrome, apnea,
patent ductus arteriosus (PDA) with
left-to-right shunt, and infection
asphyxia, hypoglycemia, and hypocalcemia
8
Q
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
a
9
Q
By 4 days after birth, tremors at rest
signal central nervous system disease
from various possible causes, ranging
from asphyxia to drug withdrawal
A
a
10
Q
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
a
11
Q
Newborns who do not demonstrate
these behaviors may have a neurologic
condition, drug withdrawal, or a
serious illness such as infection
A
a
12
Q
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
a
13
Q
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
a
14
Q
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
a
15
Q
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
a
16
Q
If a cooperative infant fails items on a standardized screening instrument, developmental delay is possible, necessitating more precise testing and evaluation.
A
a
17
Q
An infant or toddler who has developmental
skills that plateau or are out of
sequence may have autism or cerebral
palsy.
A
a
18
Q
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
a
19
Q
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
a
20
Q
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
a
21
Q
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
a
22
Q
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
a
23
Q
Chronic conditions causing reduced length or height include neurologic, renal, cardiac, gastrointestinal, and endocrine disorders as well as cystic fibrosis
A
a
24
Q
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
25
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
26
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
```
27
```
Causes of sustained hypertension in
newborns include renal artery disease
(stenosis, thrombosis), congenital renal
malformations, and coarctation of the
aorta
```
a
28
```
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
29
Bradycardia may be from drug ingestion,
hypoxia, intracranial or neurologic
conditions, or, rarely, cardiac
dysrhythmia such as heart blockage.
a
30
Extremely rapid and shallow respiratory
rates are seen in newborns with
cyanotic cardiac disease and right-toleft
shunting, and metabolic acidosis.
a
31
Fever can raise respiratory rates in
infants by up to 10 respirations per
minute for each degree centigrade
of fever
s
32
Tachypnea and increased respiratory
effort in an infant are signs of lower
respiratory disease such as bronchiolitis
or pneumonia
a
33
```
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
34
```
Potentially sick febrile infants under
3 months of age may have serious
bacterial infection and should have
temperatures assessed using a rectal
thermometer
```
a
35
Anxiety may elevate the body temperature
of children. Excessive bundling of
infants may elevate skin temperature
but not core temperature
a
36
```
Temperature instability in a newborn
may result from sepsis, metabolic
abnormality, or other serious conditions.
Older infants rarely manifest
temperature instability
```
a
37
Some newborns with polycythemia
have a “ruddy” complexion. This is a
reddish purple color
a
38
```
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
39
```
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
40
```
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
41
Skin desquamation is normal in fullterm
newborns but may rarely be a
sign of placental circulatory insufficiency
or congenital ichthyosis
a
42
Both erythema toxicum and pustular
| melanosis may appear similar to
the pathologic vesiculopustular rash of herpes simplex or Staphylococcus
aureus skin infection
43
Midline hair tufts over the lumbosacral
spine region suggest a possible
spinal cord defect
a
44
Jaundice within the first 24 hours of
birth may be from hemolytic disease of
the newborn
a
45
Late-appearing jaundice or jaundice
that persists beyond 2 to 3 weeks
should raise suspicions of biliary
obstruction or liver disease
a
46
```
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
47
```
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
48
```
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
49
Dehydration is a common problem in
infants. Usual causes are insufficient
intake or excess loss of fluids from
diarrhea
a
50
An enlarged posterior fontanelle may be
| present in congenital hypothyroidism.
a
51
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
52
```
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
53
Early closure of the fontanelles can be
due to developing microcephaly or to
craniosynostosis or some metabolic
abnormalities
a
54
```
Delayed closure of the fontanelles is
usually a normal variant, but can be
due to hypothyroidism, megalocephaly,
increased intracranial pressure, or
rickets
```
a
55
A depressed anterior fontanelle may
| be a sign of dehydration.
a
56
Dilated scalp veins are indicative of longstanding
| increased intracranial pressure
a
57
```
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
58
```
Plagiocephaly may also reflect pathology
such as torticollis from injury to
the sternocleidomastoid muscle at
birth or lack of stimulation of the
infant.
```
a
59
```
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
60
```
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
61
Micrognathia may also be part of a
syndrome, such as the Pierre Robin
syndrome.
a
62
Most developmental and genetic
syndromes with abnormal facies also
have other abnormalities
a
63
```
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
64
```
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
65
```
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
66
A newborn who truly cannot open an
eye (even when awake and alert) may
have:
Causes include:
congenital ptosis
birth trauma
CN III palsy
67
Subconjunctival hemorrhages are
common in neonates born via vaginal
delivery
a
68
```
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
69
```
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
70
```
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
71
Colobomas may be seen with the
naked eye and represent defects in
the iris.
m
72
```
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
73
Persistent ocular discharge and tearing
beginning at birth may be from
dacryocystitis or nasolacrimal duct
obstruction
m
74
Failure to progress along these visual
developmental milestones may indicate
delayed visual maturation
a
75
```
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
76
Occlusion of the lens may represent a
| cataract
m
77
```
Small retinal hemorrhages may occur
in normal newborns. Extensive hemorrhages
may suggest severe anoxia,
subdural hematoma, subarachnoid
hemorrhage, or trauma
```
m
78
Small, deformed, or low-set auricles
may indicate associated congenital
defects, especially renal disease.
m
79
```
Otitis media (see pp. 869–870) can
occur in infants.
```
m
80
```
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
81
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
82
```
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
83
Rarely, supernumerary teeth are noted.
These are usually dysmorphic and are
shed within days but are removed to
prevent aspiration.
pg.827
84
Although unusual, a prominent, protruding
tongue may signal congenital
hypothyroidism or Down syndrome
a
85
```
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
86
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
87
```
Macroglossia is associated with several
systemic conditions. If associated with
hypoglycemia and omphalocele, the
diagnosis is likely Beckwith–Wiedemann
syndrome.
```
a
88
A congenital fissure of the median
| line of the palate is a cleft palate
a
89
```
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
90
```
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
91
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
92
```
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
93
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
```
94
A fracture of the clavicle may occur during
birth, particularly during delivery of
a difficult arm or shoulder extraction
a
95
Two types of chest wall abnormalities
| noted in childhood include
pectus excavatum “funnel chest,”
pectus carinatum “chicken breast deformity.”
96
```
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
97
```
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
98
Lower respiratory infections, defined
as infections below the vocal cords,
are common in infants and include
bronchiolitis and pneumonia.
a
99
Acute stridor is a potentially serious
| condition; causes include
laryngotracheobronchitis
(croup), epiglottitis,
bacterial tracheitis, foreign body, hemangioma,
or a vascular ring
100
```
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
101
Asymmetric chest movement may
| indicate a space-occupying lesion
a
102
```
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
103
Children with muscle weakness may
be noted to have thoracoabdominal
paradox at several years of age.
a
104
```
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
105
Biphasic sounds imply severe obstruction
from intrathoracic airway narrowing
or severe obstruction from
extrathoracic airway narrowing
a
106
Diminished breath sounds in one side
of the chest of a newborn suggest
unilateral lesions (e.g., congenital diaphragmatic
hernia or pneumothorax).
a
107
Upper respiratory infections are not
serious in infants but can produce
loud inspiratory sounds that are often
transmitted to the chest.
a
108
```
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
109
```
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
110
In general, cardiac causes of central
cyanosis involve right-to-left shunting
and can be caused by a variety of
congenital cardiac lesions
a
111
The combination of tachypnea, tachycardia,
and hepatomegaly in infants
suggests heart failure.
A
112
A diffuse bulge outward of the left
side of the chest suggests longstanding
cardiomegaly
a
113
```
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
114
PDA is associated with hyperdynamic
precordium and bounding distal
pulses
a
115
```
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
116
```
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
117
```
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
118
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
119
```
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
120
Distant heart tones suggest pericardial
effusion; mushy, less distinct heart
sounds suggest myocardial dysfunction
a
121
```
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
122
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
123
A louder-than-normal pulmonic component,
particularly when louder than
the aortic sound, suggests pulmonary
hypertension
a
124
```
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
125
The third heart sound (S3) should be
differentiated from the higher-intensity
third heart sound gallop, which is a
sign of underlying pathology.
a
126
Fourth heart sounds (S4), not often
heard in children, are low-frequency,
late diastolic sounds, occurring just
before the first heart sound
a
127
```
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
128
Any of the noncardiac findings that
frequently accompany cardiac disease
in children markedly raises the possibility
that a murmur is pathologic.
a
129
```
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
130
```
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
131
A newborn with a heart murmur and
central cyanosis is likely to have congenital
heart disease and requires
urgent cardiac evaluation
a
132
```
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
133
A single umbilical artery may be associated
with congenital anomalies or
be an isolated anomaly.
a
134
An umbilical granuloma at the base of
the navel is the development of pink
granulation tissue formed during the
healing process
a
135
Infection of the umbilical stump
(omphalitis) can be a serious condition
and is characterized by periumbilical
edema and erythema
839
136
```
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
137
An increase in pitch or frequency of
bowel sounds is heard with gastroenteritis
or, rarely, with intestinal obstruction
a
138
A silent, tympanic, distended, and
| tender abdomen suggests peritonitis
a
139
```
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
140
```
Several diseases can cause splenomegaly,
including infections, hemolytic
anemias, infiltrative disorders,
inflammatory or autoimmune diseases,
and portal hypertension
```
a
141
```
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
142
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
143
```
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
144
A fixed, downward bowing of the
penis is a chordee; this may accompany
a hypospadias
s
145
```
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
146
```
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
147
```
Ambiguous genitalia, involving masculinization
of the female external
genitalia, is a rare condition caused by
endocrine disorders such as congenital
adrenal hyperplasia
```
a
148
```
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
149
An imperforate hymen may be noted
| at birth
a
150
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
151
```
Careful inspection can reveal gross
deformities such as dwarfism, congenital
abnormalities of the extremities or
digits, and annular bands that constrict
an extremity
```
a
152
Skin tags, remnants of digits, polydactyly
(extra fingers), or syndactyly
(webbed fingers) are congenital
defects noted at birth
a
153
A fracture of the clavicle can occur
| during a difficult birth.
a
154
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
155
Developmental dysplasia of the hip
is important to detect as early
treatment has excellent outcomes.
a
156
A soft audible “click” heard with these
maneuvers does not prove a dislocated
hip, but should prompt a careful
examination.
a
157
```
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
158
```
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
159
```
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
160
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
161
Pathologic tibial torsion occurs only in
association with deformities of the feet
or hips
a
162
True deformities of the feet do not
return to the neutral position even
with manipulation.
a
163
The most common severe congenital
foot deformity is talipes equinovarus
or clubfoot
a
164
```
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
165
```
Subtle neonatal behaviors such as
fine tremors, irritability, and poor selfregulation
may indicate withdrawal
from nicotine if the mother smoked
during pregnancy
```
a
166
```
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
167
```
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
168
If changes in facial expression or cry
follow a painful stimulus but no withdrawal
occurs, weakness or paralysis
may be present
a
169
Abnormalities in the cranial nerves
suggest an intracranial lesion such
as hemorrhage or a congenital
malformation
a
170
Congenital facial nerve palsy can result
from birth trauma or developmental
defects
a
171
Dysphagia, or difficulty in swallowing,
can occasionally be due to injury to
cranial nerve IX, X, and XII
a
172
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
173
As in adults, asymmetric reflexes
| suggest
a lesion of the peripheral nerves or spinal segment
174
```
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
175
When the contractions are continuous
(sustained ankle clonus), central
nervous system disease should be
suspected
a
176
```
A newborn who is irritable, jittery and
has tremors, hypertonicity, and hyperactive
reflexes may have drug withdrawal
from maternal substance use
during pregnancy
```
a
177
```
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
178
```
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
179
```
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
180
Developmental delay across more
than one domain (e.g., motor plus
cognitive) suggests more severe
disease
a
181
Persistence of palmar grasp reflex
beyond 4 months suggests pyramidal
tract dysfunction
a
182
Persistence of clenched hand beyond
2 months suggests central nervous
system damage, especially if fingers
overlap the thumb
a
183
Persistence of plantar grasp reflex
beyond 8 months suggests pyramidal
tract dysfunction.
a
184
Absence of rooting indicates severe
generalized or central nervous system
disease
a
185
Persistence beyond 4 months
suggests neurologic disease (e.g.,
cerebral palsy); persistence beyond
6 months strongly suggests it
a
186
Asymmetric response suggests
fracture of clavicle or humerus or
brachial plexus injury.
a
187
```
Persistence beyond 2 months
suggests asymmetric central nervous
system development and sometimes
predicts the development of cerebral
palsy.
```
a
188
Absence suggests a transverse spinal
| cord lesion or injury
850
189
Persistence may indicate delayed
| development
850
190
Persistence may indicate delayed
| development
851
191
Delay in appearance may predict
future delays in voluntary motor
development
851
192
```
Lack of reflex suggests hypotonia or
flaccidity.
Fixed extension and adduction of legs
(scissoring) suggests spasticity from
neurologic disease, such as cerebral
palsy.
```
851
193
Absence of placing may indicate
paralysis.
Newborns born by breech delivery
may not have a placing reflex
851
194
```
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
195
```
Young children can have inadequate
weight and height gain if caloric
intake is insufficient. Etiologies
include psychosocial, interactional,
gastrointestinal, and endocrine
disorders
```
a
196
Most children with exogenous obesity
are also tall for their age. Children
with endocrine causes of obesity tend
to be short.
a
197
```
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
198
```
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
199
```
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
200
```
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
201
```
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
202
The epidemic of childhood obesity
has also resulted in a rising prevalence
of childhood hypertension.
a
203
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
204
```
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
205
```
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
206
Fetal alcohol syndrome can cause
abnormal facies
microcephaly
developmental delay
207
Strabismus (see Table 18-7,
Abnormalities of the Eyes, Ears, and
Mouth, p. 916) in children requires
treatment by an ophthalmologist
a
208
```
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
209
```
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
210
```
Reduced visual acuity is more likely
among children who were born
prematurely and among those with
other neurologic or developmental
disorders.
```
a
211
```
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
212
The most common visual disorder of
childhood is myopia, which can be
easily detected using this examination
technique.
a
213
Some children develop abnormalities
in near vision, which can lead to reading
difficulties, headaches, and school
problems, as well as double vision
a
214
With acute mastoiditis, the auricle
may protrude forward and outward,
and the area over the mastoid bone is
red, swollen, and tender
A
215
```
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
216
```
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
217
With otitis externa (but not otitis
media), movement of the pinna elicits
pain.
a
218
Movement of the tympanic membrane
is absent in middle ear effusion
(otitis media with effusion
a
219
Significantly, temporary hearing loss
for several months can accompany
otitis media with effusion.
a
220
```
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
221
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
222
The two types of hearing loss seen
in children are conductive and
sensorineural hearing loss.
a
223
Causes of conductive hearing loss
include congenital abnormalities,
trauma, recurrent otitis media, and
tympanic membrane perforation
a
224
Causes of sensorineural hearing loss
include hereditary congenital infections,
ototopic drugs, trauma, and
some infections such as meningitis
a
225
Pale, boggy nasal mucous membranes
are found in children with allergic
rhinitis
a
226
Purulent rhinitis is common in viral
infections but may be part of the constellation
of symptoms of sinusitis
a
227
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
228
Nasal polyps are flesh-colored
growths inside the nares. They are
generally isolated findings, but can
be part of a syndrome.
a
229
```
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
230
```
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
231
```
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
232
```
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
233
Malocclusion and misalignment of
teeth can be from thumb sucking, a
hereditary condition, or premature
loss of primary teeth
a
234
Common abnormalities include
coated tongue in viral infections, and
strawberry tongue, from scarlet fever.
a
235
Children who are severely “tonguetied”
| might have a speech impediment
a
236
A geographic tongue is a benign but
chronic condition in which a portion
of the tongue has a rough, unusual
appearance
a
237
```
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
238
A peritonsillar abscess is suggested by
erythema and asymmetric enlargement
of one tonsil, pain, and lateral
displacement of the uvula
a
239
Acute epiglottitis is now rare in the
United States because of immunization
against Haemophilus influenzae type B.
a
240
Bacterial tracheitis can cause airway
| obstruction
a
241
```
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
242
The epidemic of childhood obesity
has resulted in many children who
snore and have sleep apnea
a
243
```
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
244
Lymphadenopathy is usually from viral
or bacterial infections (see Table 18-8,
Abnormalities of the Teeth, Pharynx,
and Neck, p. 917).
a
245
```
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
246
```
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
247
```
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
248
```
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
249
With upper airway obstruction such
as croup, inspiration is prolonged and
accompanied by other signs such as
stridor, cough, or rhonchi
a
250
With lower airway obstruction such as
| asthma, expiration is
prolonged and
| often accompanied by wheezing
251
Pneumonia in young children is generally
manifested by fever, tachypnea, dyspnea,
and increased work of breathing
a
252
```
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
253
```
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
254
In coarctation of the aorta the blood
pressure is lower in the legs than in
the arms.
a
255
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
256
```
Pathologic murmurs that signify cardiac
disease can first appear after
infancy and during childhood. Examples
include aortic stenosis and mitral
valve disease.
```
a
257
An exaggerated “pot-belly appearance”
may indicate malabsorption from celiac
disease, cystic fibrosis, or constipation or
aerophagia.
a
258
```
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
259
Chronic or recurrent abdominal pain
is relatively common in children.
Causes include both functional
disorders and organic disorders
a
260
```
Functional disorders causing
abdominal pain include irritable bowel
syndrome, functional dyspepsia, and
childhood functional abdominal pain
syndrome
```
a
261
```
Organic causes of chronic or recurrent
abdominal pain in children include
gastritis or ulcer, gastroesophageal
reflux, constipation, and inflammatory
bowel disease
```
a
262
```
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
263
```
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
264
Hepatomegaly in young children is
unusual. It can be caused by cystic
fibrosis, protein malabsorption, parasites,
fatty liver, and tumors
a
265
If hepatomegaly is accompanied by
splenomegaly, portal hypertension,
storage diseases, chronic infections,
and malignancy should be considered
a
266
```
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
267
An abdominal mass felt on
palpation may represent stool from
constipation, or a serious condition
such as a tumor
a
268
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
269
Precocious puberty is due to excess
androgens and can be caused by multiple
conditions including adrenal or
pituitary tumors
a
270
Cryptorchidism may be noted at this
age. It requires surgical correction.
It should be differentiated from a
retractile testis
a
271
Possible causes of a painful testicle
include infection such as epididymitis
or orchitis, torsion of the testicle, or
torsion of the appendix testis
a
272
```
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
273
Inguinal hernias in older boys present
as they do in adult men with swelling
in the inguinal canal, particularly
following a Valsalva maneuver
a
274
The appearance of pubic hair before
age 7 years should be considered
precocious puberty and requires
evaluation to determine the cause
a
275
```
Rashes on the external genitals
can be from physical irritation,
sweating, and candidal or bacterial
infections including streptococcal
infection
```
a
276
```
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
277
```
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
278
Precocious puberty can induce menses
| in a young girl
a
279
Purulent, profuse, malodorous, and
blood-tinged discharge should be
evaluated for the presence of infiltration,
foreign body, or trauma
a
280
```
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
281
```
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
282
```
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
283
Anal skin tags are present in inflammatory
bowel disease but are more
often an incidental finding when
located in the midline
a
284
Tenderness noted on rectal examination
of a child usually indicates an
infectious or inflammatory cause,
such as an abscess or appendicitis
a
285
```
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
286
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
287
```
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
288
```
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
289
```
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
290
```
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
291
Problems with social interaction, verbal and nonverbal communication,
restricted interests, and repetitive
behaviors could be signs of
autism
292
```
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
293
```
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
294
Children with mild cerebral palsy may
have both slightly increased tone and
hyperreflexia.
a
295
```
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
296
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
297
Delayed or disordered development
in early childhood can lead to early
school failure as well as social, behavioral,
and emotional problems
a
298
```
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
299
```
Children with meningitis, encephalitis,
or cerebral abscess can have
abnormalities of cranial nerves,
although they also have altered
consciousness and other signs
```
a
300
Although facial nerve palsy can be
congenital, it is often caused by
infection or trauma
a
301
```
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
302
Causes of sustained hypertension for
this age group include primary hypertension,
renal parenchymal disease,
and drug use
a
303
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
304
Moles or benign nevi may appear during
adolescence. Their characteristics
differentiate them from atypical nevi,
described on p. 912.
a
305
An adolescent with persistent fever,
tonsillar pharyngitis, and cervical
lymphadenopathy may have infectious
mononucleosis.
a
306
A pulmonary flow murmur accompanied
by a fixed split second heart
sound suggests right-heart volume
load such as an atrial septal defect
a
307
Breast buds (pea-size firm masses inferior
to the nipple) are common among
both girls and boys entering puberty
or during early puberty.
a
308
Breast asymmetry is common in adolescents,
particularly when adolescents
are between Tanner stages 2 and 4. This
is nearly always a benign condition.
a
309
```
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
310
```
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
311
Hepatomegaly in teens may be from
infections such as hepatitis or infectious
mononucleosis, inflammatory
bowel disease, or tumors.
a
312
Delayed puberty is suspected in boys
who have no signs of pubertal development
by 14 years of age.
a
313
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
314
```
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
315
```
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
316
```
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
317
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
318
```
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
319
```
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
320
Obesity in females can be associated
| with early onset of puberty
a
321
```
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
322
```
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
323
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
324
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
325
```
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
