THE PEDIATRIC DIAGNOSTIC EXAMINATION - PART 8 pdf

2. IntertrigoBright red, some scaling Obese pts., rubbing A, C Mistaken for monilia or erosions of intertriginous skin 3. Petechiae Location of trauma, Pt. generally A, C, I Accidental, self-inflicted, abuse, “factitious,” ruptu redhealthy cultural practices (coining) capillaries; facial petechiae with severe coughing or vomiting II. Blue macules 1. Blue nevus Sharply circumscribed, may Anywhere I, C, A Benign be papular 2. Melanoma Irregular borders, Sun- exposed A, C Fair-skin, + family history nonuniform pigment, areas variegated color, >4 cm in diameter 3. Tattoo Artistic pattern, but may be Anywhere A, C History of trauma, FB (e.g., secondary to foreign body pencil). III. Purple macules Ecchymoses/ Traumatic in normal patient, Anywhere I, C, A Review “Petechiae” above purpura but also consider all causes under “Petechiae” above 563 (Continued) TABLE 16–1 Macules (Continued) Configuration Pattern and Clinical Etiology and Associated Systemic and Color Characteristics Distribution Age Incidence Diagnoses, Comments IV. Brown macules A. Diffuse Generalized hyperpigmentation 1. Endocrine Stria (Cushing), oral Anywhere, more in A, C, I Addison, Cushing, disease hyperpigmentation sun-exposed areas hyperthyroidism (Addi son), vitiligo, proptosis, goiter (↑ thyroid) 2. Metabolic Kayser-Fleischer ring, CNS A, C Wilson, hemochromatosis disease sx (Wilson), hair and nail changes (hemochromatosis) 3. Hepatic diseas e Pruritus, jaundice, A, rarely CBiliary cirrhosis xanthomata 4. Drug-induced Hx of malignancy, malaria, A, C, I Antimalarial, anticancer, cardiac arrhythmiaand antiarrhythmic medications B. Local ized hyperpigmentation 1. Acanthosis Brown to black; may be Axillae, neck, A, C, I Insulin resistance, polycystic nigricans papular; associated with knuckles and ovary syndrome (PCOS) obesity and insulin elbows resistance; amenorrhea, hirsuitism 564 2. Nevi Uniform, regular border,Anywhere A, C, rarely I Watch for malignant change round 3. Lentigo Nevi, atrial myxoma, myx. Anywhere A, C, I NAME syndrome syndromesfibroma, ephelidesLEOPARD syndrome Lentigo, ECG abn., ocular hypertelorism, pulm. stenosis, abnormal genitalia, retardation, deafness Lentigo, GI polyps, Peutz-Jeghers syndrome premature puberty 4. Becker nevus Brown to black, irregular Shoulder and trunk A, C pigmentat ion, satellites, contains hairs 5. Café-au-lait spot Tan, regular, >0.5 cm, >five,Diffuse A, C Neurofibromatosis type I axillary freckles, Lisch nodules, optic gliomas, neurofibromas Tan, irregular, unilateral, Unilat eral, single McCune-Albright syndrome precocious puberty, bone or multiple dysplasia 6. Postinflammatory Any inflammatory lesion; Location of original A, C, I Eczema, drug rash, excoriations hyperpigmentation more in darker-skinnedle sions individuals (Continued) 565 TABLE 16–1 Macules (Continued) Configuration Pattern and Clinical Etiology and Associated Systemic and Color Characteristics Distribution Age Incidence Diagnoses, Comments 7. Fungal infection. Brown, circular, some Anywhere, more on I, C, A Tinea corporis, cruris, or capitis scaling, clear center; may thighs, crural area, (ringworm) be red; hair loss and trunk Diaper rash, red to brown Penis, scrotum labial Monilial diaper rash with satellite lesions Streaky rash, lightly Shoulder, neck C, A Tinea versicolor to hypopigmented, occasional scales V. White macules A. Diffuse (total)Total body pigment loss Diffuse I, C, A Eye findings: nystagmus, photophobia, ↑ skin ca, 1. Albinism Melanin loss, eczematous Diffuse I, C, A Retardation (MR), seizures rash 2. Phenylketonuria Albinism 3. Hematologic Total pigment loss, sharply Diffuse I, C, A problems demarcated H ermansky-Pudlak Platelet dysfunction, bleeding Chediak-Higashi WBC abnormality, infection B. Localized 1. Piebaldism Face, trunk, back, I, C, A Genetic testing available proximal May be associated with deafness extremities (e.g., Waardenburg with white and symmetrical forelock, heterotropia of iris) 566 2. Tuberous Multiple small Diffuse C, A, often not Seizures, MR sclerosishypopigmented lesions, detected in +Wood light, Shagreen infancy patches (raised plaques), Angiofibromas on faceFace, nasolabial (formerly Adenoma folds Se baceum) 3. IncontinentiaDiffuse, preceded by Swirling pattern I, C, A Developmental delay, usually pigmenti vesicular lesions (Blaschko) lethal in males, ectodermal abn. 4. Nevus Large areas of Linear pattern C, A, rarely I Usually isolated, but rarely depigmentosus hypopigmentation(dermatomal) assoc. with neurologic abn. 5. Halo nevus Pigmented center,surrounding Anywhere C, A Benign, depigmented area of depigmentation lymphocytic infi ltration 6. Pityriasis alba Discrete, may be scaling Face and neck A, C, rarely I Associated with atopy 7. Postinflammatory Localized to areas of original Anywhere A, C, I Multiple causes, allergic, toxic, hypopigmentationinflammationinfectious/inflammatory 8. Tine a versicolor See above under Neck, back C, A Fungal postinflammatory hyperpigmentation 9. VitiligoDiffuse, sharp, milk-white Anywhere, A, C, I Absent melanocytes, may be nonsymmetricsecondary to endocrine o r immune disorder Abbreviations: HSM = hepatosplenomegaly; CMV = cytomegalovirus; TSST = toxic shock syndrome toxin; DIC = disseminated intravascular coagulation; Pts = patients; Assoc. = associated; Abn = abnormal. 567 TABLE 16–2 Papules Configuration Pattern and Clinical Etiology and Associated Systemic and Color Characteristics Distribution Age Incidence Diagnoses, Comments I. Red papules A. Infectious 1. FolliculitisPinpoint, in hair follicules, Hair location, esp. A, C, rarely I Staph. Pseudomonas from pools may form pustules, upper body and hot tubs; ↑ in abscess immunocompromised pt. 2. Sca rlet fever Pinpoint “sandpapery,” redDiffuse, ↑ in axilla C, A Group A strep. rarely viral cheeks, circumoral pallor and groin (scarlatiniform) Strawberry tongue, Pastia’s lines antecubital fossa area 3. Lyme dise ase Eryth. chronicum migrans, Location of tick bite A, C Borrelia burgdorferi, assoc. ring (railroad track edges) cardiac, neurol., and arthritis 4. Fungal See Table 16–1. ScalesAnywhere, abscess A, C Tinea cr uris (groin), barbis infection Pustules, abscess more on hands, (beard), versicolor, others feet, and scalp 5. Secondary Maculopapular, scaly Anywhere, palms A Adenopathy, HSM, syphilisand soles Treponema pallidum 6. Warts Pink, scaly, or keratot ic; Anywhere, plantar, C, A Papilloma virus hypopigmented; may periungual be flesh 7. Gianotti-Crosti Small red papules Face, extremities, C, occ I Viral prodrome, HSM, buttocks subsequent hepatitis 8. Scabies Papules with burrows, Web of f ingers, groin A, C less in I Sarcoptes scabii, pruritus may form vesiclesmore diffuse in infants 568 B. Allergic 1. Papular Small raised papules, Anywhere C, A, I Pruritic, self-limited, also may urticaria blanchesbe viral; may be larger, polymorphous w/clear centers (E. multiforme) 2. Insect bitesSimilar to pap. ur t., entry Exposed areas C, A, I Pruritic, self-limited site, excoriations from scratching 3. Drug eruption Pink-red, may be scaly Symmetric, oral A, C, I Occ. pruritic, unrelated to lesionsduration of me dication 4. Eczema Pink, scaly plaque, secondary Antecubital and I, C, A Pruritic, remissions and flares, to weeping, excoriation, popliteal fossae; associated with asthma; ↑ or ↓ pigment with behind ears, neck, nummular eczema more in healing; may be nummular hands; more diffuse adolescents (coin-like), pin point and on cheeks in follicular in dark skin pt.infants 5. Contact Papules initially, may form Exposed areas; pattern C, A, I Very pru ritic, does not spread dermatitiscrusts, plaques & vesicles. of contact (streaksby scratching unless antigen May be excoriatedfor poison ivy, is present, e.g., rhus oil from patch below poison ivy umbilicus for nickel from belt buckle) 569 (Continued) TABLE 16–2 Papules (Continued) Configuration Pattern and Clinical Etiology and Associated Systemic and Color Characteristics Distribution Age Incidence Diagnoses, Comments C. Inflammatory 1. Miliaria Tiny red papules; occ. vesicle Neck and back; I, C, A Red-miliaria rubra, vesicle- sweat-exposedmiliaria crystallina 2. Acne Red or flesh papules Face, forehead, back A, C Plugged oil glands (whiteheads) (comedones) black papulesbecome inflamed (blackheads) (open comedones), may be or infected (pustules) pustular 3. Vasculitis a. Blanching 1. Juvenile rheum. Discrete red evanescent maculesAnywhere I, C, A Arthritis, lymphadenopathy, arthritis (JRA) and papules w/fever hepatosplenomegaly (HSM) 2. Lupus Red papules with scale; over Sun-exposed or malar A, C Multisystem disease, psych erythematosus time get pigment change, areaproblems, renal, arthritis atrophy, telangiectasia 3. Kawasaki Papular/macular Anywhere; erythema I, C Persistent fever, disease of palms and soles; lymphadenopathy, arthritis, mucus membrane coronary aneury sm. involvement b. Petechial See “Petechiae,” TABLE 16–1 See “Petechiae,” See “Petechiae,” TABLE 16–1 TABLE 16–1 570 4. Granulomatous disease a. Common 1. Granuloma Ring, clear center, rubbery Dorsum hands and, A, C Often mistaken for ringworm. annulare papules on edge. feet extensor Self-limiting surfaces 2. Pyogenic Red, vascular, f riable Anywhere, often of C, A Bleed easily. Needs excision. granuloma face and hands 3. Foreign body Red brown papules Location of FB I, C, A Remove foreign body (FB) b. Rare Red brown papules Anywhere Consider leprosy, sarco idosis, TB and atypical mycobacteria. D. Other leishmaniasis, fungal disease 1. Seborrhea Scaly, greasy, occ crusts Scalp, eyebrows, I, C, A “Cradle cap” in infants and plaques eyelids, cheeks, intertriginous areas 2. Keratosis Perifollicula r, pinpoint, pink, Extensor surface of A, C, I Assoc. with dry skin (eczema, pilarishorny papules arms and thighs ichthyosis) 3. Pityriasis, Large herald patch, salmonTrunk, proximal A, C Mild itching, self-limiting rosea color oval small patches in extremitie s (up to 3 months), mistaken “Christmas tree” pattern, scaly for tinea 4. PsoriasisRed plaques, may be pustular,Anywhere, but often A, C Chronic or recurrent, mild itch, sharp margins, white-silvery extensor surfaces, often mistaken for eczema, scale; may have guttate scalp tinea, or seborrhea; guttate- (droplike) pattern, nailtype assoc. with strep. and pitting is self-limited Often mistaken for eczema 571 (Continued) [...]... about 3 weeks Hair growth ceases, and the hair bulb dislodges itself from the dermal papilla The end of the hair now has a blunt club shape to it Telogen This is the resting phase, which lasts 3 to 4 months The hair now assumes a mace-like shape at the base and dislodges itself with the onset of the new anagen phase At any given time 70 percent or more of hair is in the anagen phase, so ongoing hair loss... shaft Examination of hair is by observation and palpation Key findings related to each of the problems are enumerated below Synthesizing a Diagnosis 591 KEY FINDING Hair Loss Pattern Is the hair completely or partially absent? Is the shaft intact or abnormal? Is there a differential in length of hairs that are present? Is the hair loss in patches or diffuse? What is the shape of the patch? Are there... develops the nail matrix The matrix is the area of growth, producing the more visible distal nail plate The white crescent at the base of the nail (lunula) is the distal end of the nail matrix A normal newborn has fully developed nails Problems Nail disorders are either congenital or acquired Thus a full history is paramount to arriving at a diagnosis Key historical points are • When did the patient... other ectodermally derived structures (CNS, eyes, and teeth)? Is there difficulty with temperature control, as manifest by excessively warm skin or lack of perspiration? Does the general physical examination lead to any other systemic conditions? Synthesizing a Diagnosis The best approach is to use the patient history to categorize whether the condition is congenital/genetic, metabolic/toxic, infectious/inflammatory,... Are there abnormalities of the skin underlying the area of hair loss such as inflammation or scarring, or is the underlying skin smooth? Are there hair stubbles present? Distribution Is the hair loss focal or diffuse? Did it begin focal and spread, or has it always been diffuse? What specific areas are involved? General Physical Examination Are there any abnormalities of other ectodermally derived structures... dermatology is morphology-driven, there are still key historical points to cover: • Time of onset? Congenital or acquired? • How does the condition progress? Does it wax and wane? Is it becoming steadily worse? • Is there a patient history of systemic illness that may explain the problem? • Is there a family history of a similar condition? • Are there associated systemic symptoms and signs with the present condition?... syndromes include Coffin-Siris syndrome, mucopolysaccharidoses, leprechaunism, trisomy 18, Marshall-Smith syndrome, and others Consult a text on dysmorphology for further detail NAILS The goals of this section are 1 To review developmental anatomy of the nails 2 To enumerate key historical and physical findings 3 To develop differential diagnoses for nail abnormalities Developmental Anatomy The nails begin... methicillin-resistant Staphylococcus aureus; PCR = polymerase chain reaction; HPV = human papilloma virus; synd = syndrome; TB = tuberculosis 590 Chapter 16: The Integument System—Skin, Hair, Nails Physiology The normal hair cycle consists of the following phases: Anagen This represents active growth, where the hair follicle begins in the deep dermis and wraps itself around the dermal papilla The loose... is often a consequence of a high fever, infection, stress such as surgery, and certain drugs There is loss of hair over a 3- to 5-month period Although distressing, the hair invariably grows back over several months Presence of club-shaped hairs supports this diagnosis Anagen effluvium is the result of chemotherapy and heavy metal intoxication Traumatic Traumatic hair loss is common in children and... In toddlers, this may be a normal means of self-stimulation to induce sleep (often with hair twirling and thumb sucking), but in older children and adolescents, it may be a manifestation of an obsessive-compulsive disorder Typically, there is not complete hair loss in the patches, and the length of each hair is variable In small infants, particularly with the present “back to sleep” movement, many have . contraception , collagen-vascular disease 4. Panniculitis a. Cold Red, indurated, nontender,Cheeks, or other I, C Crystallization and rupture of may have plaquesareas if cold- fat cells, self-limiting exposed b Inflammatory 1. Miliaria Tiny red papules; occ. vesicle Neck and back; I, C, A Red-miliaria rubra, vesicle- sweat-exposedmiliaria crystallina 2. Acne Red or flesh papules Face, forehead, back A,. Sun-exposed or malar A, C Multisystem disease, psych erythematosus time get pigment change, areaproblems, renal, arthritis atrophy, telangiectasia 3. Kawasaki Papular/macular Anywhere; erythema