(18) Peds Tables Flashcards

Question

Congenital Syphilis

Answer 1

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).

Answer 2

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

Answer 3

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.

Answer 4

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

Answer 5

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.

Answer 6

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).

Answer 7

These abnormal speckling spots on the iris suggest Down | syndrome

Answer 8

Strabismus, or misalignment of the eyes, can lead to visual | impairment. Esotropia, shown here, is an inward deviation.

Answer 9

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

Answer 10

This infection is common in infants. The white plaques do not rub off

Answer 11

Tender ulcerations on the oral mucosa are surrounded by | erythema

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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.

Answer 16

This baby has total anomalous pulmonary venous return and | an oxygen saturation level of 80%.

Answer 17

The best location to examine is the mucous membranes. Cyanosis is a “raspberry” color, whereas normal mucous membranes should have a “strawberry” color.

Answer 18

This baby has mild cyanosis above the lips, but the mucous | membranes remain pink

Answer 19

Normal pigment deposition in the vermilion border of the lips gives them a bluish hue, but the mucous membranes are pink

Answer 20

This commonly appears on the feet and hands of babies | shortly after birth. This infant is a 32-week-old newborn

Answer 21

Usually a normal valve annulus with fusion of some or most of the valve leaflets, restricting flow across the valve

Answer 22

``` 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 ```

Answer 23

``` 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 ```

Answer 24

``` 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 ```

Answer 25

``` 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 ```

Answer 26

``` 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 ```

Answer 27

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

Answer 28

``` 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 ```

Answer 29

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.

Answer 30

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

Answer 31

``` 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 ```

Answer 32

``` Single loud second sound of the anterior aortic valve Frequent rapid development of heart failure Frequent associated defects as described at the left ```

Answer 33

``` 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. ```

Answer 34

``` 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 ```

Answer 35

``` 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. ```

Answer 36

Continuous flow from aorta to pulmonary artery throughout the cardiac cycle when ductus arteriosus does not close after birth

Answer 37

``` 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 ```

Answer 38

``` 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 ```

Answer 39

Left-to-right shunt through an opening in | the atrial septum, possible at various levels

Answer 40

``` Location. Upper left sternal border Radiation. To the back Intensity. Variable, usually grade II–III/VI Quality. Ejection but without the harsh quality ```

Answer 41

``` 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 ```

Answer 42

1. Marked and immediate dilatation of the anus in knee–chest position, with no constipation, stool in the vault, or neurologic disorders 2. Hymenal notch or cleft that extends >50% of the inferior hymenal rim (confirmed in knee–chest position) 3. Condyloma acuminata in a child older than 3 yrs 4. Bruising, abrasions, lacerations, or bite marks of labia or perihymenal tissue 5. Herpes of the anogenital area beyond the neonatal period 6. Purulent or malodorous vaginal discharge in a young girl (culture and view all discharges under a microscope for evidence of a sexually transmitted infection)

Answer 43

1. Lacerations, ecchymoses, and newly healed scars of the hymen or the posterior fourchette 2. No hymenal tissue from 3 o’clock to 9 o’clock (confirmed in various positions) 3. Healed hymenal transections especially between 3 and 9 o’clock (complete cleft) 4. Perianal lacerations extending to external sphincter

Answer 44

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

Answer 45

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

Answer 46

- 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

Answer 47

pg. 923 | pictures but no real info