Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2920_Библиотеки_им_академика_М_И_Перельмана

attention to any recent infection or trauma, in­cluding birth trauma. Has the infant or any fam­ily member had a recent rash or fever? Ask about any changes in the infant’s behavior, such as frequent vomiting, lethargy, or disinterest in feeding.

ISTORY AND PHYSICAL

weight loss), the anterior fontanel appears slightly depressed. Other findings include pale, dry skin and mucous membranes; decreased urine output; a normal or slightly elevated pulse rate; and possibly irritability.

Severe dehydration (15% or greater weight loss) may result in a markedly sunken fontanel along with extremely poor skin turgor, parched mucous membranes, marked oliguria or anuria, lethargy, and signs of shock, such as rapid, thready pulse, very low blood pressure, and ob­tundation.

Continue to monitor the infant’s vital signs and intake and output, and watch for signs of wors­ening dehydration. Obtain serum electrolyte values to check for an increased or decreased sodium, chloride, or potassium level. If the pa­tient has mild dehydration, provide small amounts of clear fluids frequently or provide an

Tests to evaluate dehydration include urinaly­sis for specific gravity and possibly blood tests to determine blood urea nitrogen and serum creatinine levels, osmolality, and acid-base status.

may develop after the acute stage of po­liomyelitis, producing a steppage gait. This sign is usually preceded by fever, asymmetrical mus­cle weakness, coarse fasciculations, paresthe­sia, hypoactive or absent DTRs, and permanent muscle paralysis and atrophy. Dysphagia, urine retention, and respiratory difficulty may also occur.

of stroke along with arm and leg weakness or paralysis. Other effects vary according to the site and severity of vascular damage. Sensori­motor disturbances may include paresthesia, dysphagia, visual field deficits, diplopia, and bowel and bladder dysfunction. Personality

changes, amnesia, aphasia, dysarthria, and de­creased level of consciousness may also occur.

Instruct the patient in the use of assistive de­vices, such as canes, crutches, or walkers, as necessary. Review the importance of asking for assistance with activities to prevent falls and promote safety. Include the patient’s family in this teaching.

duration of swallowing difficulties, if any. Are liquids more difficult to swallow than solids? Is swallowing more difficult at certain times of the day (as occurs in the bulbar palsy associated with myasthenia gravis)? If the patient also has trouble chewing, suspect more widespread neu­rologic involvement because chewing involves different cranial nerves.

Brain stem glioma is an important cause of ab­normal gag reflex in children.

ISTORY AND PHYSICAL

Instruct the patient in the use of assistive de­vices as necessary. Review the components of a safe environment, such as establishing a clear path to the bathroom and using proper footwear.

Ask the patient when his gait impairment first developed and whether it has recently wors­ened. Because he may have difficulty remem­bering, having attributed the gait to “old age,” you may be able to gain information from family members or friends, especially those who see the patient only sporadically.

Propulsive gait, usually with severe tremors, typically occurs in juvenile parkinsonism, a rare form. Other rare causes include Hallervorden­Spatz disease and kernicterus.

during the late recovery stage of bilateral occlu­sion of the anterior cerebral artery. The patient may also display leg muscle paraparesis and at­rophy, incoordination, numbness, urinary in­continence, confusion, and personality changes.

appears late in this disorder and may improve with treatment. The patient may also experi­ence sensory ataxia, changes in proprioception and vibration sensation, optic atrophy, and de­mentia.

Because of the sensory loss associated with scissors gait, provide meticulous skin care to prevent skin breakdown and pressure ulcer for­mation. Also, give the patient and his family complete skin care instructions. If appropriate, provide bladder and bowel retraining.

The major causes of scissors gait in children are cerebral palsy, hereditary spastic paraplegia, and spinal injury at birth. If spastic paraplegia is present at birth, scissors gait becomes apparent when the child begins to walk, which is usually later than normal.

Spastic gait—sometimes referred to as paretic or weak gait—is a stiff, foot-dragging walk caused by unilateral leg muscle hypertonicity. This gait indicates focal damage to the corti­cospinal tract. The affected leg becomes rigid, with a marked decrease in flexion at the hip and knee and possibly plantar flexion and equino­varus deformity of the foot. Because the pa­tient’s leg doesn’t swing normally at the hip or knee, his foot tends to drag or shuffle, causing his toes to scrape on the ground. To compen­sate, the pelvis on the affected side tilts upward in an attempt to lift the toes, causing the pa­tient’s leg to abduct and circumduct. Also, arm swing is hindered on the same side as the af­fected leg.

Causes of spastic gait in children include sickle cell crisis, cerebral palsy, porencephalic cysts, and arteriovenous malformation that causes he­morrhage or ischemia.

ISTORY AND PHYSICAL