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متخصص کودکان-فوق تخصص نوزادان

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Presentation on theme: "متخصص کودکان-فوق تخصص نوزادان"— Presentation transcript:

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2 متخصص کودکان-فوق تخصص نوزادان
معاینه نوزاد دکتر محمود نوری شادکام متخصص کودکان-فوق تخصص نوزادان (MD-MPH) دانشیار گروه کودکان

3 اهمیت موضوع شناخت اندازه ها و خصوصیت های طبیعی
پیدا کردن مسائل غیر طبیعی که بعضاً نیاز به اقدامات اورژانسی دارد (3-1 % نوزادان ناهنجاری مادرزادی دارند)

4 شرح حال در طب نوزادی 1-اطلاعات دموگرافیک
2-ناخوشی های طبی گذشته در مادر و خانواده 3-مشکلات باروری قبلی مادر 4-حوادث بارداری کنونی 5-توصیف زایمان

5 توانایيهاي تعاملي و ارتباطی
نوزاد بلافاصله پس از تولید هوشیار بوده و در صورتیکه فرصت داده شود آماده شیر خوردن است نوزاد نزدیک بین است (فاصله کانونی بینایی حدود 12-8 اینچ است) شنوایی به خوبی تکامل یافته است. پس از ارتباط اجتماعی اولیه که حدود 40 دقیقه طول می کشد یک دوره خواب آلودگی به نوزاد دست می دهد.

6 اندازه های طبیعی HT HC WT

7 وضع ظاهری حرکات خشن و لرزشی همراه با میوکلونوس مچ پا و فک در نوزادان شایعتر و کم اهمیت تر از سنین دیگر است. چنین حرکاتی بیشتر در زمانی که نوزاد فعال است دیده می شود، در حالیکه انقباضات تشنجی بیشتر در حالت آرامش به وجود می آید. نوزاد ادم ندارد

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9 Vernix A grayish-white cheeselike substance, consisting of sebaceous gland secretions, lanugo, and desquamated epithelial cells, that covers the skin of the fetus and newborn. Vernix is theorized to serve several purposes 1-moisturizing the infant's skin 2-Facilitating passage through the birth canal 3-Serves to conserve heat and protect the delicate newborn skin from environmental stress. There is little evidence to support a chemical role of vernix in protecting the infant from infection, it may form a physical barrier to the passage of bacteria.

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11 Acrocyanosis Assessment of color — A normal infant appears pink. Acrocyanosis, a bluish appearance of the hands, feet, and perioral area, is common in the first few days after delivery. However, central cyanosis, which is seen best on the tongue and mucous membranes of the mouth, suggests hypoxemia.

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14 Mongolian spots Mongolian spots are the most frequently encountered pigmented lesions in newborns. There are marked racial differences in prevalence : 90 percent in Asian,American,African&Indian Neonates >60 percent in black neonates 46 to 70 percent in Hispanic neonates <10 percent in white neonates

15 Mongolian spots The lesions are results of the delayed disappearance of dermal melanocytes. The sacral area and medial buttocks are sites where active dermal melanocytes frequently remain at birth. Dermal melanocytosis is less often seen in extra sacral ("aberrant") sites, eg, the superior or anterior trunk and extremities. A biopsy, which is rarely indicated, shows the widely spaced dermal melanocytes in the deep dermis.

16 Mongolian spots Mongolian spots are completely benign and usually
fade during the first or second year of life. By 6 to 10 years of age, the vast majority have disappeared. However, approximately 3 percent remain into adulthood, particularly those in extra sacral locations

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18 Harlequin color change
 Harlequin color change is observed when an infant is lying on his or her side. It is characterized by intense reddening of the dependent side and blanching of the non-dependent side, with a demarcation line along the midline. The duration ranges from a few seconds to 20 minutes. The etiology of harlequin color change is unknown. It may be related to immaturity of the autonomic regulation of cutaneous blood vessel tone .

19 Harlequin color change
Harlequin color change affects approximately 10 percent of newborns, occurring more often in preterm than term infants. The frequency is greatest in the first few days of life, but it has been observed up to three weeks after birth. Harlequin color change is entirely benign. It should not be confused with the harlequin fetus, the most severe form of congenital ichthyosis that is lethal in the neonatal period.

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22 Erythema toxicum neonatorum
 ETN occurs in 31 to 72 percent of full-term infants Declines in incidence with decreasing birth weight and gestational age. Etiology is not known, but immaturity of the pilosebaceous follicles (the combined sebaceous gland and hair follicle) may contribute.

23 Erythema toxicum neonatorum
rapidly progress to pustules on an erythematous base ETN is characterized by multiple erythematous macules and papules (1 to 3 mm in diameter) The lesions are distributed over the trunk and proximal extremities, sparing the palms and soles. They may be present at birth, but typically appear within 24 to 48 hours. The rash usually resolves in five to seven days, although it may wax and wane before complete resolution.

24 Erythema toxicum neonatorum
The diagnosis of ETN is usually made upon the basis of clinical appearance. It can be confirmed by microscopic examination of a Wright-stained smear of the contents of a pustule that demonstrates numerous eosinophils and occasional neutrophils. However, this usually is not necessary. A minority of patients (7 to 18 percent) may also have peripheral eosinophilia. ETN resolves spontaneously. No treatment is necessary.

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27 Transient neonatal pustular melanosis
 TNPM is less common than ETN. It mostly affects full-term black infants, although it is described in all races. TNPM consists of three types of lesions : Small pustules on a non erythematous base; these usually are present at birth Erythematous macules with a surrounding collarette of scale; these develop as the pustules rupture and may persist for weeks to months Hyperpigmented macules that gradually fade over several weeks to months Lesions in different stages may be present at the same time, even at birth.

28 Transient neonatal pustular melanosis
The diagnosis of TNPM is usually based upon the clinical appearance. Microscopic examination of a Wright-stained smear of the contents of a pustule demonstrates numerous neutrophils and rare eosinophils .However, this is usually not necessary. Culture, if performed, yields no organism. No treatment is necessary.

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30 Milia   Milia are white papules caused by retention of keratin and sebaceous material in the pilaceous follicles. They are frequently found on the nose and cheeks, and resolve in the first few weeks of life.

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32 Miliaria Miliaria is a common finding in newborns, especially in warm climates. It is caused by accumulation of sweat beneath eccrine sweat ducts that are obstructed by keratin at the level of the stratum corneum.

33 Miliaria Miliaria rarely is present at birth. It usually develops during the first week of life, especially in association with warming of the infant by an incubator, occlusive dressings or clothing, or fever. It is characteristically distributed on the face, scalp, and intertriginous areas.

34 Miliaria The diagnosis of miliaria is based upon the clinical features. Microscopic examination of a Wright-stained smear of the contents of a vesicular lesion demonstrates sparse squamous cells and lymphocytes. However, this is usually not necessary. No specific treatment is needed. Lesions usually resolve rapidly when the infant is placed in a cooler environment with associated measures to reduce sweating, such as light, loose clothing and cool baths.

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36 Epidermolysis bullosa
 Epidermolysis bullosa (EB) is a group of inherited diseases characterized by skin fragility and blister formation caused by minor skin trauma. EB is broadly classified into three groups by the level at which the blisters form. These are EB simplex, junctional EB, and dystrophic EB. Separation is at the intraepidermal, intra-lamina lucida, and sub-basal lamina levels, respectively.

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38 Salmon Patch (Nevus Simplex)
Salmon patches are small, pale pink, ill-defined, vascular macules that occur most commonly on the glabella, eyelids, upper lip, and nuchal area of 30-40% of normal newborn infants. These lesions, which represent localized vascular ectasia, persist for several months and may become more visible during crying or changes in environmental temperature. Most lesions on the face eventually fade and disappear completely, although lesions occupying the entire central forehead often do not. Those on the posterior neck and occipital areas usually persist. The salmon patch is usually symmetric, with lesions on both eyelids or on both sides of midline.

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40 Port Wine Stains Port wine stains (PWS) are almost always evident at birth and are a capillary malformation. They are usually sporadic, although some occur in families in an apparently autosomal dominant inheritance.  They are initially pink or red, and grow in proportion to infant growth.  Although they may appear to lighten in the first few months, they generally darken after this. They can be associated with other skin anomalies such as extensive mongolian spots.  Treatment of PWS is possible using a laser, although improvement rather than complete resolution is most common.

41 معمولا در صورت دیده می شود و باید معاینه کننده را به یاد سندرم استورج وبر (انژیوماتوز عصب سه قلو،تشنج و کلسیفیکاسیون ”ریل مانند“ داخل جمجمه ای در همان طرف ) بیندازد

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43 Neonatal Acne Neonatal acne may be present at birth, or develop over the first 2-4 weeks of life.  There is controversy over whether it is truly acne or whether it represents a form of pustular disorder in the newborn period.  The condition consists of pustules over the cheeks primarily, but also involves other areas of the face and the scalp.  As opposed to infantile acne (which develops after 2 months) and acne of adolescence, there are no comedomes in the neonatal form. Neonatal acne resolves spontaneously and without scarring.

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45 Aplasia cutis congenita
 Aplasia cutis congenita (ACC) is a group of heterogeneous diseases characterized by congenital focal absence of the skin. It is most often limited to a solitary midline posterior scalp lesion, but other presentations include several smaller scalp defects or involvement of the extremities or trunk .Clinical subtypes are characterized by their location and pattern of lesions, associated malformations, and mode of inheritance .

46 Aplasia cutis congenita —
ACC is usually an isolated condition. However, other malformations may be associated. These include trisomy 13 or 4p- syndrome, cleft lip and palate, and defects of the hands and feet . A subtype characterized by a ring of long dark hair surrounding a congenital scalp lesion (hair collar sign), may indicate an associated cranial neural tube defect such as an encephalocoele, meningocele, or heterotopic brain tissue [. One proposed mechanism is that this may arise from an abnormality of separation of the epithelial and neural ectoderm at the time of neural tube closure.

47 Aplasia cutis congenita
The etiology of ACC is uncertain, but it may result from a failure of ectodermal fusion during embryogenesis. Treatment usually consists of conservative wound care. Most lesions will reepithelialize spontaneously; larger lesions may require surgical intervention

48 جمجمه ملاج قدامی mm 10± 20 ملاج سوم فقط در نوزادان نارس طبیعی است
ملاج خلفی 5 x 5 mm می باشد. فونتال بزرگ در جریان هیدروسفالی،هیپوتیروئیدیسم و راشیتیسم دیده میشود

49 چشم ها با بلند کردن وعقب و جلو بردن آرام نوزاد، چشم ها به خودی خود باز می شود. خونریزی های ملتحمه و شبکیه معمولاً خوش خیم است. رفلکس های مردمک بعد از هفته حاملگی نمودار می شود. قطر قرنیه در نوزاد ترم کمتر از 1cm حضور رفلکس قرمز دوطرفه بیانگر عدم کاتاراکت و پاتولوژی داخل چشم است.

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56 لکوکوریا ممکن است ناشی از کاتاراکت،تومور چشم،کوریورتینیت شدید،زجاجیه اولیه هیپرپلاستیک پایدار و رتینوپاتی نارسی باشد.

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58 دهان مرواریدهای ابشتاین وکیست های احتباسی در چندین هفته اول زندگی ناپدید می شود. اغلب در روزهای 3-2 دسته های فولیکولی با زخمی زرد یا سفید در زمینه اریتماتو بر روی ستون قدامی لوزه ها دیده می شود، علت این ضایعات ناشناخته بوده و طی 4-2 روز بدون درمان از بین می رود. نوزاد ترشح فعال بزاق ندارد. زبان نسبتاً بزرگ و فرنولوم کوتاه است. لوزه های نوزاد کوچک است.

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62 سینه هیپرترفی پستان شایع است (حتی ممکن است شیر از آن خارج شود).
فشردن سینه ها در بدو تولد باعث ورم و یا حتی تشکیل آبسه می گردد.

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65 ریه ها RR در نوزاد ترم طبیعی 60-30 بار در دقیقه
نوزاد نارس ممکن است با ریتم شین استوک تنفس کند تنفس نوزاد، غالباً دیافراگمی است. خرخر (grunting) در صورتی خوش خیم است که دقیقه بعد از تولد از بین برود. صداهای تنفسی باید در دو طرف قفسه سینه قرینه باشد و نباید بعد از 1تا2 ساعت اول زندگی،رال سمع شود.

66 قلب سوفل های خوش خیم موقتی شایع است.
سرعت طبیعی ضربان قلب ضربه در دقیقه است. فشار خون نوزاد 70/55 است. وجود اختلاف بیش از میلی متر جیوه بین فشار اندام فوقانی و تحتانی مطرح کننده کوارکتاسیون ائورت است.

67 شکم کبد معمولاً قابل لمس بوده و گاهی به اندازه 2cm زیر لبه دنده لمس می شود. نوک طحال بندرت قابل لمس است. تا 24 ساعت بعد از تولد گاز در رکتوم دیده می شود. دفع مکونیوم معمولاً در 12 ساعت نخست تولد انجام می شود (99% نوزادان ترم و 95% نوزادان نارس تا 48 ساعت بعد از تولد)

68 دستگاه تناسلی ترشح غیر چرکی از دستگاه تناسلی جنس مونث شایع است.
در بعضی از موارد در جنس مونث از دستگاه تناسلی دفع خون داریم. بیضه ها باید در اسکروتوم باشند. نعوظ آلت تناسلی شایع است. اغلب نوزادان تا 12 ساعت بعد از تولد ادرار می کنند (95% نوزادان ترم و نارس تا 24 ساعت)

69 رفلکس های نوزادی مورو در بدو تولد ظاهر شده و 6-3 ماهگی از بین می رود.
مورو در بدو تولد ظاهر شده و 6-3 ماهگی از بین می رود. Grasping در هفته 28 حاملگی ظاهر شده و 4 ماهگی از بین می رود. Rooting (طلبیدن) در هفته 32 حاملگی ظاهر شده و 6-4 ماهگی از بین می رود. قرار دادن پا در بدو تولد ظاهر شده و 6-4 ماهگی از بین می رود. نشانه بابینسکی اکستانسور یا به سمت بالا است.

70 LGA:شیرخوارانی که وزن تولد انها بیش از صدک 90 برای سن حاملگی است.
:SGAشیرخوارانی که وزن تولد انها کمتر از صدک 10برای سن حاملگی است.

71 Laboratory سطوح سرمی گلوکز در نوزادان سر موعد و سالم بندرت کمتر از mg/dl40 در 3-1 ساعت اول زندگی، کمتر از mg/dl 45 در 24-3 ساعت اول و کمتر از mg/dl 50 در دوره پس از آن است. میزان سرمی کراتینین و BUN نوزاد تا یک هفته بعد از تولد ملاک قضاوت نیست و از مقدار BUN و کراتینین مادر تبعیت می کند. Hg 16.8 ( ) WBC ( )

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