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The shape of the flow-volume curve may also be helpful in evaluating upper or central airway pathology. Central clearing with peripheral extension may lead to the formation of annular, polycyclic, and arcuate plaques, termed urticarial multiforme given its similar appearance to erythema multiforme and erythema marginatum. B, However once they start to rapidly proliferate, becoming raised, as seen in the same infant at 1 year old. Although controversy exists regarding penile growth at puberty and the appropriateness of female gender reassignment in infancy, most authors suggest a diagnostic trial of testosterone for 3 months before making a final decision about gender assignment. This condition characteristically involves no functional impairment and requires no treatment. One of the most important abnormal findings in children is the absence of breath sounds over an area of collapse or consolidation. The causative organisms are usually found in the upper respiratory tracts and are inoculated through a break in the skin; hematogenous seeding has been postulated in some cases. Most often, they are obtained after at least 1 week of symptoms, because most viral causes have improved by this time. In females, an ectopic ureter may drain into the bladder neck, urethra, urethrovaginal septum, vagina, or uterus. Neutropenia can be seen in response to medications, in congenital deficiencies (Kostmann syndrome), or in response to infections. If a patient develops oral mucositis, chlorhexidine may need to be discontinued because its high alcohol content may dehydrate the tissue. Hepatic Discoloration Generalized intrinsic discoloration of primary teeth is seen in patients with advanced hepatic disease associated with persistent or recurrent jaundice and hyperbilirubinemia. The midline of the back is inspected for evidence of abnormal pigmentation and the presence of hemangiomas, nevi, hairy tufts, dimples, masses, or defects, which may be associated with underlying bony or neural anomalies (see Chapter 16). Rare systemic findings in children with urticaria pigmentosa include chronic diarrhea, gastric ulcers, flushing reactions, headaches, and failure to thrive. Active correction may be demonstrated by gentle stroking of the foot, stimulating the peroneal muscles to contract. In younger children, a "lap exam" may be a useful way to examine an apprehensive child. Conjunctival vesicles and keratitis may also occur, and topical antibiotics are indicated to prevent secondary bacterial infection. Common esodeviations seen in children are infantile esotropia, accommodative esotropia, esotropia resulting from sixth cranial nerve palsy, and Duane syndrome. This happens more often in conditions associated with hemoglobin (Hgb) C, but also with Hgb S, D, and E. These appear as striking bright red discolorations underneath the bulbar conjunctiva. Acquisition of motor milestones during infancy and childhood follows a relatively orderly and predictable course, albeit with a wide range of normal variation in rate. Recent evidence does suggest prolonged rest may be deleterious to the athlete postconcussion in terms of recovery. The lingual frenulum extends almost to the tip of the tongue in early infancy and then gradually recedes. Patients have been shown to have an increased number of sweat glands and prominent sebaceous glands. In children seen early or who have taken antibiotics, radiographic findings may demonstrate early acute osteomyelitis. This is osteitis, or inflammation of bone, rather than osteomyelitis, or deep bone infection. Heritable Defects of Enamel and Dentin Amelogenesis Imperfecta Amelogenesis imperfecta is the term used to describe a group of genetically determined defects that involve the enamel of primary and permanent teeth without affecting dentin, pulp, or cementum. The decreased circulating plasma volume is reflected by the thinned, narrow heart shadow seen on a chest radiograph. Even rarer is Kerner-Morrison syndrome, in which the patient experiences intractable secretory diarrhea, hypokalemia, and dehydration. On reduction, pain relief is immediate and return of function is evident within 10 to 15 minutes.
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This stems from the fact that the secondary centers of ossification in these young people have not yet fused to the pelvis. Developmental Anomalies of the Optic Nerve Developmental anomalies of the optic nerve include colobomas, tilted discs, and optic nerve hypoplasia. They are more likely to localize pain, and point tenderness is generally easy to elicit. Other features of pubertal development, including growth acceleration and pubic hair development, are absent. Although they may occur for unknown reasons, often they are manifestations of an underlying neurologic disorder, such as Charcot-Marie-Tooth disease, Friedreich ataxia, or spinal cord tethering (see Chapter 16). In it, an injury causing forceful abduction of the thumb results in rupture of the ulnar collateral ligament at the base of the thumb. Whether balanitis or posthitis indicates the need for circumcision is determined on an individual basis once the acute inflammation has resolved. The rash persists for 1 to 3 months if untreated and then clears spontaneously, marking the beginning of a period of latency in which the organism persists in Molluscum Contagiosum the sharply circumscribed, waxy, papular, umbilicated lesions of molluscum contagiosum, caused by a poxvirus, can be spread as a result of sexual contact, in which case lesions are found predominantly on the labia, mons pubis, buttocks, and lower abdomen. In some patients, vertebral flattening is noted in later childhood and adolescence. Physical Examination the orthopedic examination involves a systematic assessment of posture, stance, and gait; the symmetry or asymmetry of paired musculoskeletal structures and their motion; muscle strength and tone; and neurovascular status. B, Anterior view of the craniofacial skeleton of a child with right-sided unilateral coronal synostosis. Patient comfort may be increased by identifying and then touching distal areas first and moving proximally. Its name can be somewhat misleading, because children are still at risk for severe, and potentially fatal, infections. Patients with high fever and toxicity require parenteral treatment, as do children who fail to improve on oral medication. Hormonal changes and inattention to careful dental hygiene are thought to be contributory. Not all hydronephrotic kidneys are truly obstructed, and a Lasix renal scan will assess both the function and drainage of the kidney. In some patients mild erythema and scaling of the scalp occur in association with partial alopecia. Signs of complete intestinal obstruction may occur with associated ileus, emesis, and bloody stools. X-ray findings can be subtle, necessitating careful comparison with radiographs of the normal hand. Because the presence of underlying injuries is often indicated by the degree and nature of overlying soft tissue trauma, assessment begins with external inspection of facial structures for swelling, deformity, contusions, abrasions, and lacerations. Posterior uveitis (inflammation of the posterior vitreous, retina, and/or choroid) can be caused by infection, but frequently the precise cause is undetermined. Autoimmune diseases or disorders of immune dysregulation (such as, celiac disease or autoimmune enteropathy) are MalabsorptiveDiarrhea Malabsorption is a common cause of diarrheal illness due to the increased osmotic load placed on the intestine from the malabsorbed substance. Transmission requires close contact to permit the direct spread of large droplets. Transient irritation without discharge is common in the young child as a result of exposure to chemical irritants and inconsistent hygiene. In a small proportion of patients with vitiligo, other autoimmune conditions, such as alopecia areata, thyroiditis, diabetes, or pernicious anemia, can be detected concomitantly. The beam of the slit lamp is used to demonstrate corneal subepithelial infiltrates (small white opacities). Expression of vasopressin and oxytocin genes occurs in the hypothalamic paraventricular and supraoptic nuclei. To avoid confusion, the canal should be inspected as the speculum is inserted to ensure that the transition between canal wall and tympanic membrane is visualized. Platelet transfusions may be required during episodes of bleeding but are not routinely given as prophylaxis unless the peripheral count is less than 10,000 cells per microliter. Permanent vision loss from sickle cell retinopathy is rare in the pediatric age group.
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Any layer of the scrotal wall or any of the contents of the scrotum may produce a clinically evident lesion. The rarity of joint swelling and the absence of fever and other systemic symptoms help to rule out rheumatic and collagen vascular disorders. The mediastinal masses that produce these findings often pose considerable anesthetic risk. Their usual pretibial and extensor location helps differentiate the lesions from thrombophlebitis. The hemangioma morphology of these lesions is described as segmental, because they seem to cover a territory rather than arising from a single point. Asymptomatic nonenlarging pseudocysts can be followed clinically with serial imaging studies to resolution. Fibrous adhesions (preputial skin bridges) result when the free edge of the circumcising incision adheres to the glans penis. Both pathways contribute to the conversion of factor X into its activated form (Xa), leading to thrombin generation. A, Early in the course of adenitis caused by Mycobacterium tuberculosis or atypical mycobacteria, enlargement of the node is gradual, tenderness is mild, and there is little or no sign of warmth or overlying inflammation. Thus, specific alterations in physical appearance should alert physicians to a possible abnormality in anterior pituitary development potentially associated with secondary hormone deficiencies. Treatment is generally unnecessary for patients who are asymptomatic, and surgery is not routinely advised because the recurrence rate may be as high as 20%. Extensive necrosis, sequestrum formation, and decompression caused by fistulization through the overlying soft tissues are characteristic findings. Patients may present with a history of recurrent pneumonia or sinus disease; it is worth noting that the large majority of patients with cystic fibrosis demonstrate pansinusitis radiographically. Although fever and an abnormal gait are the most common presenting complaints, lower abdominal and groin pain, hip or buttock pain, sciatica, and thigh pain (with swelling) can be prominent early complaints. Electrical impulses in the visual cortex produced by light stimulation of the retina can be measured by placement of sensitive electrodes on the overlying scalp. When these areas have been cleared and/or stabilized, then the examiner may proceed with the orofacial examination, assessing the extent and nature of injuries. Confrontation visual fields are especially valuable in the detection of visual field defects that respect the vertical midline, which are typically caused by neurologic conditions. Patients previously exposed to a macrolide antibiotic should be treated with a regimen that does not include clarithromycin. Frenulectomy, simple division of the frenulum, may be therapeutic but is rarely necessary. Specifically, patients should receive appropriate pain medication and emotional support. Vertical transmission occurs when bacteria, such as Streptococcus mutans, pass from caregiver to child through saliva. Susceptibility to disease appears to be related to a lack of bactericidal antibody or to a failure to produce antibody in response to infection. Other Nonpharmacologic Therapies Percutaneous cholecystostomy can be performed under fluoroscopy in severely ill patients with acute cholecystitis who are not surgical candidates, especially for acalculous cholecystitis (Am J Surg 2013;206:935). Vaginoscopy is required only occasionally in the prepubertal child in order to perform a complete evaluation for complaints such as vaginal bleeding with or without evidence of trauma, discharge resistant to routine therapy, a suspected vaginal foreign body, and suspected vaginal tumors. Prior to proceeding with the biopsy, it is critical to determine respiratory status and review a chest x-ray to determine if there is bulky mediastinal disease as a component of the lymphoma. Recurrence of intussusception after reduction is seen in approximately 10% of patients. The clinical features, especially among girls with mosaic forms of Turner syndrome, can be quite variable. Priapism Priapism is a persistent, painful erection in which the corporal bodies are firmly erect but the glans is soft. In the absence of SpecimenCollection If a prepubertal child with vaginal discharge or perineal or urinary complaints is to be evaluated, it is advisable to ask the family not to bathe the patient or to apply any creams for at least 12 hours before the examination. Wilson disease is a disorder of copper metabolism and can present either as chronic hepatitis or during an acute crisis.
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Hyaline casts form on polymerization of Tamm-Horsfall glycoprotein, which is a well-characterized molecule uniquely found in the ascending limb of Henle and distal convoluted tubule. Fractures Involving the Elbow Supracondylar, condylar, intercondylar, and epicondylar humerus fractures and proximal radius and ulna fractures all involve the elbow, and the major mechanism is a fall onto the arm with the elbow in hyperextension. They also have an associated response to dependency and therefore appear to swell when placed in a dependent position. Patients with limited life expectancy due to non-liver-related comorbid conditions do not require treatment. Color Vision Change in color vision, particularly the ability to perceive red, is an early feature seen in disorders that compromise the function of the optic nerve. The roots of the teeth are anchored in the sockets of the alveolar processes of the mandible and maxilla by an encompassing periodontal membrane or ligament. On examination, the scapula is noted to be hypoplastic and high riding in association with asymmetry of the base of the neck and shoulders. Cellulitis Due to Extension of Infection From Deeper Structures Although less common than the other forms, cellulitis resulting from extension of infection and inflammation from deeper structures may also occur, necessitating close attention to examination of underlying structures in evaluation of cellulitis. At this stage, the nevus cells are limited to the epidermal/ dermal junction and are called junctional nevi. Various formulations are available, each targeting different parts of the tubular gut, and are useful for both inducing and maintaining remission in mild to moderate disease. These lesions appear as red spots with a spider leg appearance that blanch with palpation, then rapidly return when released. The phenomenon is more prevalent among AfricanAmerican prepubertal school-age girls. Microcephaly Microcephaly is defined as a head circumference more than 2 standard deviations below the mean for age, gender, and conceptual age. Because of this, it is often possible to infer the likely mechanism of injury once the fracture pattern is documented radiographically. Development for Children With Skeletal Dysplasias Growth should be monitored using specialized growth charts for height, weight, and head circumference. On examination, orbital fractures frequently have periorbital and subconjunctival hematomas. Plain film shows capsular swelling and lateral displacement of the proximal left femur. As noted earlier, ultrasonography is useful in the initial evaluation of girls suspected of having genital tract obstruction, bearing in mind its limitations in visualization of internal reproductive structures after the neonatal period and before puberty, which is when they are very small given minimal amounts of estrogen and gonadotropins. The dose can then be tapered on a weekly basis, because glucocorticoids are not recommended for maintenance therapy, and steroid-sparing alternatives should be sought for patients who appear dependent on these medications. Typically this develops after a fall with a twist, to which the unsteady toddler is unusually prone. Twisting and compression from postoperative adhesions, amniotic bands, omphalomesenteric (vitelline) remnants. Placement of a prosthetic material may provide coverage when the defect cannot be closed primarily. Clinical Presentation Acute diarrhea Viral enteritis and bacterial infections with Escherichia coli and Shigella, Salmonella, Campylobacter, and Yersinia spp. Group A -streptococci are the usual causative organisms and are detected by Gram stain and culture of vesicular fluid. If the dislocation is unilateral, the skin folds of the thighs and buttocks are often asymmetrical and the involved lower extremity appears shorter than the opposite side. Other treatment measures include use of moisturizers, topical steroids, and oral antihistamines for acute lesions. With time, however, deformities become more fixed as a result of contracture of soft tissue structures. Bilious emesis is a hallmark of intestinal obstruction and should be considered a surgical emergency until proven otherwise. The exanthem is a discrete, pinkish red, fine maculopapular eruption, which, like measles, typically begins on the face and spreads cephalocaudally.
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A, this 2-day-old infant has flaccid paresis limited to the upper extremities and associated congenital flexion contractures. B, Radiograph revealed separation of the epiphysis at the base of the distal phalanx. Conversely, over diagnosis should be avoided because it can lead to unnecessary anxiety and unwarranted treatment. Rarely, the patient may undergo a surgical procedure for the rectal prolapse before the underlying diagnosis is suspected. A simple ranula is a retention cyst in the floor of the mouth that is confined to sublingual tissues superior to the mylohyoid muscle. If a gonorrhea culture is necessary (to test for antibiotic sensitivities), insert a sterile swab into the endocervical canal, rotate it for at least 10 seconds, and then immediately place it into a selective transport or culture medium. Lyme arthritis generally presents with a more indolent and less toxic course than routine septic arthritis. If the visual axis is involved, scar formation may permanently affect visual acuity. When hypospadias is associated with cryptorchidism, karyotype should be determined. Exercise-induced asthma, the most common pulmonary problem affected by exercise, can often be identified by history of cough, shortness of breath, or chest tightness with exercise. Typically, there is one enlarged node in the chain, and it may be tender and firm. In the absence of hematuria on dipstick screening, numerous natural chromogens and vitamins found in foods, dyes, or medications may alter the normal yellow-amber color of urine imparted by the hemoglobin breakdown product urochrome (Box 14. This examination should include careful inspection of the external genitalia and regional lymph nodes, and palpation of the uterus and adnexa when indicated. Obstruction of the female genital tract by vaginal atresia, a cloacal malformation, or an imperforate hymen may cause hydrocolpos in infancy that may manifest as a large abdominal mass with respiratory embarrassment secondary to diaphragmatic compression. Patients with recurrent symptoms should have a repeat ultrasound and an attempt at enema reduction if positive. The combination of obesity, insulin resistance, dyslipidemia, and hypertension has been termed the metabolic syndrome or syndrome X. Hence the liquid ingested has more prolonged contact with dental surfaces and oral flora. Submandibular, submental, preauricular, anterior cervical, inguinal, or epitrochlear node may be the site of involvement, although cervical is most common. In particular, false positives are not caused by foods or drugs but can occur in certain medical situations, including up to 8 weeks after an abortion. Although less common than sickle cell disease, anemia associated with Hgb C is not rare in the African-American population. Some centers perform suture craniectomy with helmet therapy, especially for the unicoronal coronal synostosis, where symmetry is difficult to achieve. Infantile rickets marked by widened wrists (A) and enlargement of the costochondral junction ("beading") (B). Mild local erythema around a wound, an impetiginous lesion, or a pustule may have been noted before the abrupt onset of increased pain and the rapid evolution of subcutaneous inflammation that herald the development of cellulitis. Neurofibromin, its gene product, acts as a tumor suppressor, and its function is altered in affected patients. A graft is tissue that is completely removed from one part of the body and placed in a new recipient site in hopes that a new blood supply will grow into it to keep the graft alive. In contrast to accidental injuries, those that result from sexual abuse tend to be more posteriorly located and typically involve tears of the posterior portion of the hymen, the posterior fourchette, or perineal body. On inspection, the clinician finds a smooth, flat membrane with a thin lucent central line overlying the introitus.
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Note that the congenital structural anomalies are the most common etiology throughout the pediatric years especially early in life. B, Mild erythema and edema are evident in the periorbital area of an infant whose laceration from a dog bite had been sutured 48 hours earlier. Alternatively, empiric treatment with albendazole or over-the-counter pyrantel pamoate may be instituted. B, these lesions are dusky centrally and their peripheral rims are beginning to vesiculate. Clinical factors often can make this diagnosis, although one laboratory study that may be of value is the serum ferritin determination. Therefore persistent adenopathy, even in that setting, should be monitored closely. Suprasternal and intercostal retractions reflect excessive negative pleural pressure and can be seen in normal children with thin chest walls after vigorous exercise. Rotation is assessed by turning the foot medially and then laterally with the knee flexed. Upper respiratory tract irritation with epistaxis may lead to the mistaken notion that hemoptysis is occurring. Cysticercosis results from fecal/oral transmission of the ova shed by the adult intestinal tapeworm, and it is often transmitted to affected children by family, household, or community contacts who carry the adult T. Even when there are fractures, they are more likely to be partial (greenstick) than complete. Extensive abrasions should be covered with water-soluble, medicated gauze after irrigation. Meconium ileus disease is the initial presentation of cystic fibrosis in up to 20% of children, and these findings may be appreciated on antenatal ultrasound imaging. This mutation is the result of the deletion of three base pairs in the gene and results in a protein missing a phenylalanine residue at amino acid position 508. Patients adequately treated for lice still have nonviable shells attached to the hair. The phenotype associated with ovotesticular disorder can range from slightly virilized female to almost fully virilized male; this disorder is defined by the presence of ovarian tissues with follicles and testicular tissue with seminiferous cords. A and B, the numbers represent the average age of eruption for the teeth, indicated in months for the primary teeth and years for the permanent dentition. Tacrolimus dosing is based on trough blood levels (recommended maintenance levels of 5-10 ng/mL). Patients who have specific complaints at acute care visits also warrant inspection of the genitalia in addition to abdominal, inguinal, and (when indicated) rectal examination. Extrinsic Discoloration Extrinsic discoloration is limited primarily to patients with poor oral hygiene, those receiving certain medications, those who heavily consume stain-containing foods or drinks, or those who smoke or chew tobacco or other substances. Although these hamartomas are asymptomatic and do not correlate with the extent or severity of other manifestations, they are helpful in establishing the diagnosis. Predictive factors for moderate- to high-risk disease include age <30 years at initial diagnosis, extensive anatomic involvement, perianal and/or severe rectal disease, deep ulcers, prior surgical resection, and structuring or penetrating behavior (Gastroenterology 2013;145:1459). This spot is the mite, and it can be lifted out of the burrow with a needle or the point of a scalpel blade. The initial visual impairment can occur by three mechanisms: (1) direct pressure on the globe leading to an induced astigmatism and therefore an asymmetric refractory error between the two eyes (anisometropia); (2) partial or complete occlusion of the visual axis; and (3) induction of strabismus due to the hemangiomas mass effect. Finder 17 infections in parents or siblings, particularly those requiring hospitalization, suggest possible immunodeficiency in the family. Care must be taken when using these growth charts, because the numbers of patients in the sample section are less than in the standard growth charts. If left hip abductor weakness were present, the right pelvis would tilt downward when the right leg was lifted. The tendency of Hgb C to aggregate into precipitates is responsible for the characteristic target (actually pseudotarget; see.
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Hip deformity, dislocation, and associated arthritic changes are the result of significant and prolonged imbalance of muscle pull about the hip. Gross appearance of the thick, tarlike meconium found at laparotomy in meconium ileus. A, this young boy showed unilateral parotid swelling, which was indurated and moderately tender. Molluscum is characterized by elevated, 1- to 2-mm umbilicated lesions of the eyelid skin. Both plastic and metal speculums should be moistened with warm water or water-based lubricant to increase comfort and ease of insertion. A, this patient, age 15, with distal muscular atrophy of the lower extremities demonstrates the "stork-leg" appearance. In areas such as the nape of the neck or upper back, where the overlying skin is thick enough to resist external pointing, the process may take a path of lesser resistance, burrowing outward from the center through the subcutaneous tissues and along fascial planes. In dark-skinned children, erythema and perioral pallor may be difficult to appreciate and the papules may be larger, thus producing a texture less like that of sandpaper. It is necessary to obtain comparison views of the opposite side, especially when evaluating patients with suspected physeal injuries who may have very subtle radiographic abnormalities. B, Severe pharyngotonsillitis is seen in this child, whose tonsils are markedly enlarged and covered with exudate. This lateral radiograph of the wrist shows a dorsal buckle fracture of the distal radial metaphysis. This infant demonstrates the characteristic features of the disorder: fair skin; blue eyes; and the fair, sparse brittle hair of diffuse pili torti. This endoscopic picture of the esophagus is the result of an accidental alkaline ingestion, the most common type of ingestion to cause esophageal burns. C, Endoscopic picture of the duodenum demonstrates a smooth appearance and scalloping secondary to absent villi in a patient with biopsy-proven celiac disease. Questions concerning how, when, and if to test for bleeding disorders are controversial. The current section aims to review clinical presentations that should alert the physician to the possibility of a malignant process. Some improvement of the scaling occurs with age, and topical keratolytics (such as lactic acid and salicylic acid) may provide some benefit. Gonorrhea Gonococci cause treatable bacterial cervicitis in the adolescent and, in the context of sexual abuse, vulvovaginitis in the prepubertal child. It is important to educate parents that although improvements are the rule rather than the exception, the severity of the defect, variability in wound healing, and the growth of the patient make the final result difficult to predict. Approximately one-third of untreated patients ultimately suffer severe localized infection (after an average of 10 weeks of illness), with meningitis, carditis, nephritis, and ocular infection occurring most commonly. The virus becomes integrated into the host genome and persists in the infected individual for life. Objective findings may consist of decreased tone and decreased deep tendon reflexes in the lower extremities; patchy decreases in sensation; and foot deformities consisting of broadening and shortening, deepening of the arch, and contractures of the toes. The prolapsed urethral mucosa is red, friable, and has a doughnut shape encircling the urethra. Other predisposing causes include virtually any medical insult, particularly life-threatening systemic diseases, infection, vascular insufficiency, and electrolyte abnormalities. Because pituitary adenomas may be small, bilateral inferior petrosal sinus sampling may be necessary to localize the adenoma before surgery. This 8-year-old boy demonstrates generalized muscular hypertrophy, giving him a well-developed, athletic appearance. The presence of orbital fat indicates penetration of the orbital septum and entrance into the orbit. B, Aortic angiogram demonstrates anomalous origin of pulmonary blood supply from abdominal aorta to the left lower lobe in a 7-year-old girl with extralobar sequestration. Complications of a hyphema include rebleeding, glaucoma, and blood staining of the cornea.
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Neisseria gonorrhoeae is the organism most commonly associated with polyarticular disease, but other pathogens may be responsible, particularly S. Heterozygous loss-of-function mutations are associated with familial hypocalciuric hypercalcemia. Other presenting features can include osteoporosis, dermatitis herpetiformis, abnormal liver enzymes, and abdominal pain; incidental recognition at endoscopy can also occur (N Engl J Med 2007;357:1731). Pulmonary sequestrations are abnormal, nonfunctioning pulmonary parenchymal tissue that lacks a direct communication with the tracheobronchial tree. Varicella vaccination in seronegative patients and hepatitis A vaccination (particularly in liver transplant candidates) should be considered before transplant (Clin Infect Dis 2009;49:1550). Postinflammatory hyperpigmentation can be prominent and may be the only manifestation of the rash during remissions. This presentation is best achieved with a wall chart or by projection of the letters onto a standardized reflective surface. Further, being the result of moderate to severe mechanisms of injury, fractures of underlying bony structures are common associated findings. Because young children do not complain of monocular vision loss, especially if congenital or with onset during infancy, sensory strabismus is frequently the presenting sign of vision loss caused by pathology of the retina or optic nerve. Examination of the Pubertal Patient Indications the practice of routine inspection of the external genitalia at each well-child visit beyond infancy facilitates early diagnosis of any problems that may arise and allows evaluation of physical growth and secondary sex characteristics. Idiopathic Gingival Hyperplasia Different types of patients, often with significant systemic illnesses or syndromes, may manifest generalized gingival enlargements. Premature Pubarche the development of pubic hair before 8 years old in girls and 9 1 2 years old in boys is considered to be premature. A strabismus deviation that changes in size or magnitude in different gaze positions is termed incomitant. Laxative screening should be considered when chronic diarrhea remains undiagnosed. A, An insect bite was the source of inoculation of group A streptococci in this child, who subsequently suffered secondary cellulitis and lymphangitis. Proliferative changes include arteriolar occlusions that lead to arteriovenous anastomosis, causing areas of retinal nonperfusion. After this, the normal side and then the affected side are gently palpated for warmth, induration, and tenderness. Evaluation of these parameters may provide information regarding exercise fitness and, if limited, identify whether the limiting factor is ventilatory or cardiac. An associated convex posterior chest wall prominence (termed rib hump) or paralumbar prominence may also be noted on forward bending. Hypomotility disorders may also manifest a dilated esophagus but with a gaping gastroesophageal junction and evidence of reflux disease. Deep surgical and traumatic wounds are major predisposing factors, although injection sites, cutaneous ulcers, abscesses, and omphalitis may serve as the point of origin. The size and configuration of the hemorrhage depend on the amount and location of the blood between the conjunctiva and the globe. Thus, girls with renal or urinary tract abnormalities are at greater risk for having associated anomalies of internal genital structures. The finger was swollen and painful and maximally tender at the base of the distal phalanx, and the patient was unable to extend the distal interphalangeal joint. The Ponseti technique stresses gentle manipulation and serial casting of the foot to correct the deformity. Posterior synechiae cause the pupil to be less reactive in the area of the synechiae and may cause the pupil to dilate poorly, producing anisocoria, or lose its round shape (corectopia). If the vector of the direct force is perpendicular to the bone, a transverse fracture is most likely to result, whereas direct force applied at any angle to the bone produces an oblique fracture pattern. Metabolic Diseases the mucopolysaccharidoses are syndromes caused by inherited defects in the lysosomal enzymes that degrade acid mucopolysaccharide. The scalp, face, extensor surfaces of the extremities, and buttocks are the most common sites of involvement.
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A and B, Although the child was normal at birth, fever, lethargy, and decreased feeding suddenly developed in this infant at 6 days old. An unrecognized hematoma may result in a permanent deformity if left undrained, or superinfection of the hematoma results. A, Lateral view of a child with Pierre Robin sequence, characterized by severe micrognathia and cleft palate. The knee is otherwise normal on examination, with the possible exception of mild limitation of flexion. When the dermis is also involved, lesions usually display distinct borders because of dermal inflammation and edema. The diagnosis may be confirmed by serologic testing for the antigen or by polymerase chain reaction of nodal tissue. Patients have iris transillumination defects in which the red reflex is seen through multiple punctate defects in the iris. Other Agents Other complications from topical medications, such as contact dermatitis, can be easily prevented. Although the virus can infect any area of the skin, the lips and fingers (as in herpetic whitlow) are the most common sites of involvement. Alternatively, histopathologic demonstration of organisms in tissue is also adequate for diagnosis. Pancytopenia may occur from bone marrow failure or extramedullary cellular destruction (as seen in autoimmune disease, particularly systemic lupus erythematosus) or as a combination of depressed marrow function and increased cellular destruction. Clinical deterioration/lack of improvement despite 7-10 days of intensive medical management, evidence of bowel perforation, and peritoneal signs are indications for urgent total colectomy. The external auditory canal may be atretic or stenotic, leading to conductive hearing impairment, which is far more common than neurosensory losses. Aerobic, anaerobic, and viral cultures must be obtained, because corneal involvement, particularly with gonorrhea, may lead to corneal scarring or perforation. When true clinical scoliosis is found, the patient should be referred for orthopedic evaluation no matter how small the curve is believed to be. Small bowel atresias are often isolated conditions, but other anomalies may be present in 25% of patients. Indications for stopping treatment, as per the current guidelines, include the following. In patients with more long-standing or combined infection, lesions may crust centrally and enlarge centrifugally. In establishing a diagnosis, the clinician should attend not only to the basic character of the exanthem but also to its mode of spread, its distribution, the evolution of lesions, and the constellation of associated symptoms. Various renal abnormalities have been increasingly appreciated in association with Alagille syndrome. Treatment includes dietary restriction of the offending antigen when it can be determined, high-dose proton pump inhibitor therapy, and swallowed (topical) corticosteroids, such as fluticasone and budesonide. These have a predilection for the extensor surfaces of the extremities, the scalp, and the buttocks. The presence of intraarticular fluid in the wrist is manifested by swelling and tenderness, especially evident dorsally, and by restriction of wrist motion. Note thickening and loss of the angle at the nail bed in a child with inflammatory bowel disease. A, In this patient, nasopharyngitis and purulent conjunctivitis antedated the development of a generalized sandpaper-like rash, which was tender to the touch. Internal resorption manifests clinically as a pink discoloration secondary to loss of dentin thickness. Microcornea, whether an isolated anomaly or associated with glaucoma, cataracts, iris abnormalities, or anterior segment dysgenesis, is present when the horizontal corneal diameter is 9 mm or less. Every piece of tissue in the human body is alive because the blood supplies oxygen and nutrition and carries away waste products, such as carbon dioxide. Vascular anomalies are broadly categorized into hemangiomas and vascular malformations. Two subtypes exist: A (the great majority), in which teeth are normal, and B (unusual), in which dentinogenesis imperfecta is a feature (see Chapter 21). If there is torticollis, neck exercises should be performed at each diaper change so that the chin can touch each shoulder for at least 10 seconds. Action: Slowly straighten knee until gentle stretch is felt; hold for count of 10.
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Conversely, a persistent cough that disappears in sleep strongly suggests the diagnosis of habit (psychogenic) cough. Arthralgias and a macular purpuric skin rash in the lower extremities are characteristic of this entity. Although hemoglobin values may be lower than expected, thalassemia traits do not represent a true physiologic anemia. Colobomas may occur in otherwise normal eyes or in association with microphthalmia or retinal detachment. This may occur as the result of laterally directed shearing forces or of a hyperextension injury. Yet, despite extensive disease at clinical presentation, children are much less likely to die from the disease. Rapid peripheral spread, overt lymphangitis, and regional adenitis are characteristic of streptococcal infection but are not completely specific. Evaluation of the child with a head that is abnormally large or appears to be growing at an excessive rate should include the following: Incontinentia Pigmenti Incontinentia pigmenti is a rare, X-linked dominant syndrome with cutaneous, neurologic, ophthalmologic, and dental manifestations. In such cases, diagnosis can be difficult, requiring considerable suspicion and a low threshold for obtaining specimens. As such, the normal caloric and protein requirements for growth are accordingly higher (Table 11. Treatment is typically continued until the patient fails to respond to a particular agent or the agent is no longer tolerated. Parkes Weber Syndrome Parkes Weber syndrome is characterized by overgrowth of the affected limb with small diffuse arteriovenous fistulas. Groin pain is rarely a symptom of an inguinal hernia, because the hernia is generally not associated with pain unless it is incarcerated, a surgical emergency. Omphalitis, a complication of umbilical venous catheterization in newborns, may precipitate portal vein thrombosis. Primary tumors of the testes and testicular region include germ cell tumors and paratesticular rhabdomyosarcoma. If a vaginal foreign body is suspected, vaginoscopy is indicated in consultation with a practitioner experienced in this procedure. Inspection can reveal muscle wasting and atrophy (or, conversely, hypertrophy), abnormal spontaneous activity, and abnormal resting postures. Grundwaldt Vascular anomalies represent a broad spectrum of disorders from the simple birthmark to the multisystem life-threatening disorder. C, Thick-walled vesicles on an erythematous base were noted in this child, who showed early findings of intraoral involvement. As a result, assessment of the position of comfort (abduction and external rotation are seen with effusion, hemarthrosis, and fracture; see. It presents similar craniofacial abnormalities, and its distinguishing feature is the presence of preaxial (radial) abnormalities, including radioulnar synostosis (proximal fusion) and hypoplasia or aplasia of the thumbs. The vesicular varicella lesions that clustered at sites of prior skin irritation became secondarily infected with group A -streptococci, resulting in cellulitis with intense erythema, edema, and tenderness of the auricle and periauricular tissues. Other locations include esophagus, small bowel adjacent to gastroenteric anastomoses, and within a Meckel diverticulum. B, the central clearing is nearly complete 1 day later, and within the erythematous border, the puncta of a tick bite is evident. Counseling parents to smoke outside the home and car is another important intervention that pediatricians can make. Mycoplasma culture is performed, but the organism is difficult and slow to isolate (taking 60 to 90 days), making this test of little clinical utility. Attention is also paid to identifying visual problems that warrant protective eyewear. Proptosis may be observed with several childhood tumors and may represent either a primary tumor or metastatic disease.
