SKIN AND SUBCUTANEOUS FAT The current relevance of a research: Due to its anatomic and physiologicalpeculiarities concerning children subcutaneous fat and skin take an active part in all theexchange and immune processes, they are treated as tissues that are characterized by thefast development in childhood. That is why skin and subcutaneous fat affections may bethe evidences of the affected organism. The aim of the lesson: To study the anatomic and physiological peculiarities ofskin and subcutaneous fat among children of different ages, as well as with symptoms oftheir affection. As the result of the self-training the student must know the following:1. Anatomic and physiological peculiarities of skin and subcutaneous fat.2. The skin and subcutaneous fat functions in age aspect.3. The peculiarities of skin and subcutaneous fat for newborns, physiological and transitory states of skin and subcutaneous fat within the period of newborns.4. The methods of skin and subcutaneous fat investigation.5. The skin and subcutaneous fat affection semiotics. As the result of topic covering the student must be able to:1. Collect the anamnesis, to analyse the complaints typical for the skin and subcutaneous fat affection.2. Evaluate the skin colour, its humidity, temperature, the skin fold thickness, skin elasticity, dermatographism, the state of capillaries; in case of eruption pserence one must be able to find out its nature.3. Evaluate the skin and subcutaneous fat state (turgor, oedemata, infiltration, tha state of development). Skin glands in age aspect: Oil glands may be found on all the skin districts, except for palms, feet and dorsalside of feet. Their ducts open to the hair follicle, except for lips skin, preputial bags and
small (lower) lips of pudendum, where they open on the surface directly. The oil glandsactivity depends on androgenic stimulation (the mother’s androgens stimulation forfoetus). Apocrine glands are located at axillary sockets, perianal and privy parts districts,near umbilicus. They produce the milk-like odourless secret. It is pushed out under theandrogen stimulators action to the surface. Under the influence of bacteria it becomessmelly, this smel is connected with perspiration. These glands are “sleeping” up to thepubertal period. Eccrine (merocrine) glands are spread over the whole body’s surface. Theyresponse to the temperature on hair districts and regulate the body’s temperatutre bymeans of water transportation to the skin surface where it is turned into a vapour. Theirducts are opened to the skin surface. The glands are provided with sympathetic nerveendings. Skin eruption elements: Primary: appear in visually unchanged skin. Spot (makula) – primary non-cavernous skin eruption element which changesthe skin colour only, it disappears when pressed. May be of inflammation and non-inflammation genesis. According to its size is divided into roseolas (less than 5 mm insize), proper spots and erythema (more than 20 mm in size). Among the spots of non-inflammation genesis hemorrhagic ones are the most frequent to meet; they are dividedinto petechia, purpura (2-5 mm in size), linear (vibices), ecchimozes (“bruises” >5 mm),big formless spots – sugilation (???),haematoma. The spots can be dypigmented (vitiligo,albinism), hyper pigmented (freckles, chloasma, birthmarks). Typhoid maculopapularrash is present in case of typhoid, syphilis, measles and German measles. Punctate (finelypapular) rash is typical for scarlet fever and measles. Telangiectasia (vessels units havingthe star form) are also treated as spots. They are the evidence of liver affection. Papule (papula) - is the vessel knit, non-cavernous element which changes theskin consistence and relief. Appears as the result of different pathological processestaking place in epidermis and skin upper layers (infiltrate skin accumulation, skin tissueshypertrophy, protein products precipitations. Depending on the size the following types
are distinguished: miliary, lenticularis (up to 0, 5 cm), numeral (???) (1-2 cm). they maybe of inflammation and non-inflammation (warts) genesis. Papule is most frequent incase of scab, lichen pilaris, measles, German measles and purpura rheumatica). Hunch (tuberculum) - is the non-cavernous element located in a gauze layer ofderma, up to 1 cm in diameter, prominent on the skin surface. May be of inflammationand non-inflammation nature. Is noticed in case of syphilis, wolfish herpes, leprosy andleishmaniasis. Nodule (nodus) - is the non-cavernous element located in derma. May be ofnon-inflammation (atheroma, lipoma) and inflammation (strophuloderma, leprosy,rubber, furuncle, carbuncle, nodal eryterma). Vial (vesicula) – is the primary non-cavernous element having a bottom, coverand content. If it is less than 1 cm in size, it is vial; if it is more than 1 cm in size, it isbulb (bulla). The content may be serum, hemorrhagic and purulent. May be located eitherin epidermis ar below epidermise. It is typical for eczema, chicken pox, shingles. Thebulb is typical for burns. Pustule (pustula) – is the non-cavity element with the purulent content located inepidermis, derma or subcutaneous. May be connected (osteofolliculitis, folliculitis, acneand hydradenitis) and disconnected (impetigo) with the skin appendages; deep andsuperficial. Bulb (urtica) – is the non-cavernous element (stands between the cavernous andnon-cavernous ones), form as the result of temporary surface blood vessels widening andliquid blood components release. The examples: nettle-rash, insects bites, nettle burns,allergic dermatosis). Secondary: is the stage of primary and secondary elements development. Secondary pigmentation: - the skin colour change on the place of the previouslyexisting element. Peel (squama) – the element consisting of the surface epidermis layers, skin fat,dust and bacteria. Erosion (erosio) – the defect in the epithelium boundaries. Ulcer (uslus) – is thedeep defect of skin which reaches the cellar layer, is formed of the deep primaryelements.
Excoriation (excoriatio) – scratch, abrasion. Is the linear skin defect caused inmechanic way. Crack (rhagades) – is the linear skin defect formed as the result of the skinwholeness and elasticity. Crust (crustae) – exudation which is dry; appears on the places of all thecavernous lements or at the places of secondary elements accompanied by the skinwholeness affection. Cicatrice (cicatrix) - conjunctive tissue replaces skin. Atrophy – all the skin layers get thinner. Lichenification (lichenificatio) – all the skin layers get thicker, the underlinedpicture is present (neurodermatitis, eczema). The skin is wholeness, coarse, the picture isenforced, there is a lot of furrows, practically cannot be taken to folds. The ambiguity of skin eruption elements is called polymorphism. The real (true)polymorphism is represented by several different primary elements, while the false one isrepresented by the one primary element on different stages of its development. The normotrophia, hypotrophy and paratrophy finding out and thesequence of precipitation and disappearance for children: Normotrophy – is the normally developed subcutaneous fat. Paratrophy – is overdeveloped subcutaneous fat among infants. As for elderychildren, the same symptoms stand for adiposity. Hypotrophy – is the disappearing or lowering of subcutaneous fat (SCF). Thereare three detected grades of hypotrophy: I grade – SCF disappears on stomach, lowers on body and extremities. The bodymass compromise stands for 11-20%. II grade – SCF disappears on stomach, lowers on body and extremities, butremains on a child’s face. The body mass compromise stands for 21-30%. III grade – SCF disappears even on face. The body mass compromise stands formore than 30%. SCF precipitation: face, neck and shoulders, body, extremities, stomach. SCF disapearance: stomach, hip internal surface, body, extremities, cheeks(Bish’s heaps).
Sclerema, scleredema: Sclerema (focal or diffusive) – is the process of SCF infiltration. Is noticedamong the prematurely born and weak full-term children. Most frequently appears oncheeks, hips, buttocks, body with the following spread on the neighbouring sound skinzones. The skin of these zones is cold, tense, pale or with hyperemia. Scleredema is the process of infiltration or oedema of the definite SCF zonewhich spreads over the neighbouring body zones. Tests:1. The following elements are treated as the primary skin eruption elements except for: 1.1. Spot; 1.2. Papule; 1.3. Vial; 1.4. Hunch; 1.5. Ulcer; 1.6. Pustule.2. The following elements are treated as the secondary eruption elements except for: 2.1. Cicatrice; 2.2. Peel; 2.3. Atrophy; 2.4. Hunch; 2.5. Lichenification.3. Point out the skin zones free of oil glands: 3.1. Lips; 3.2. Palms; 3.3. Neck; 3.4. Shoulders; 3.5. Stomach.4. What of the given below is not typical for the child’s skin epidermis? 4.1. Epidermis is thin, delicate and light;
4.2. The glittering epidermis layer is noticed on palms and feet only; 4.3. The melanin pigment is absent in growth layer up to the age of 6 months; 4.4. The cambial layer where the epithelium cellars growth takes place is almost undeveloped. 4.5. All the intercellar connections are very weak, that is why the superfacial layer cells are easily pilled and traumas are usual.5. “Thrush” is the following: 5.1. The patch on tonsil as the result of diphtheria; 5.2. The white pellicle in the infant’s mouth cavity left after feeding; 5.3. The fungus affection of the mouth cavity, mostly among infants; 5.4. White dots often appearing on the infants’ faces, the result of the temporary oil glands ducts closing.6. The following statements have nothing to do with the childrens’ derma peculiarities: 6.1. The quantity of collagenous (white) fibers is small, they are thin and joined into the light fascicle. 6.2. The elastic derma fibres are well developed, they are the prevaling ones during the childish age; 6.3. The papillary derma layer is not enough exposed; 6.4. The water quantity in derma is sufficiently biger for children than for adults; 6.5. The derma’s biochemical composition helps the increased skin penetration.7. Which of the given below skin peculiarities helps the newborns pemphigusdevelopment: 7.1. Collagenous (white) fibers are thin and joined into the light fascicle; 7.2. Children’ skin contains more water than that of adults; 7.3. Child’s skin is delicate and easilly injured; 7.4. The basic (basement) membrane is undeveloped; 7.5. All given above.8. Dermatographism is: 8.1. The corresponding skin vessels response on mechanic stimulation by the blunt item;
8.2. The skin response on the environment temperature change; 8.3. One of the SCF characteristics; 8.4. All given above.9. What do the jam syndrome positive reaction says: 9.1. Of the increased skin vessels fragility; 9.2. Of the periferal vessels hypo tonus;. 9.3. Of the periferal vessels hyper tonus; 9.4. Of the skin lowered turgor; 9.5. This is the physiological state for the newborn’s skin.10. The following substances sre prevailing in children’ skin: 10.1. Croton and oleic acids; 10.2. Stearic and arachidonic fat acids; 10.3. Oleic and palmitinic fat acids; 10.4. Capric and linoleic fat acids; 10.5. Palmitinic and stearic fat acids.Answers: 1.5; 2.4; 3.2; 4.4; 5.3; 6.2; 7.4; 8.1; 9.1; 10.3; MUSCULOSKELETAL (APPARATUS) SYSTEM The current relevance of a research: the high growth and bone stock (bonetissue) reconstruction tempo which take place while a lot of organs and systems arefunctionally imperfect, especially for children of early age, may lead to the highfrequency of apparatus affection. The aim of the lesson: to study the composition peculiarities and functions ofbones and muscles of children of different ages, to evaluate the state of this system and torecognize the most spread symptoms of its affection in childish age. As the result of the self-training the student must know the following:1. The peculiarities of histological composition and chemical composition of children’ bone tissue.2. The peculiarities of skull, backbone, chest and extremities among children.
3. The most frequent skeleton affection semiotics.4. The order of teeth coming out.5. The methods of bone system investigation.6. The peculiarities of histological composition and muscles tonus for children of different ages.7. The muscles affection semiotics for children.8. The methods of muscular system investigation. As the result of topic covering the student must be able to: 1. Point out complaints typical for musculoskeletal system affection; collect the family and individual anamnesis. 2. Conduct the objective bones and muscles investigation for children of different ages. 3. Evaluate the data obtained as the result of the objective investigation of the given system. 4. Work out the plan for the laboratory and instrumental musculoskeletal system investigation and evaluate the data obtained. The methodology of the musculoskeletal system investigation for children. During the children’ investigation it is necessary to exinine the anamnesis datawhich have the importance for the musculoskeletal system, static and motilitydevelopment (mother’s state of health within the pregnancy period, the character of herfeeding, the child’s state of health, the child’s feeding and the brining up regime); as wellas the typical complaints (pain in bones, muscles and joints; joints configuration changeand mobility limiting). During the examination one must pay attention on the following aspects: thehead’s form and size changes (microcephalia, macrocephaly, acrocephaly, buttocks-like,saddle-like, scaphocephaly, steeple (tower) skull, flat occiput); the upper and lower lawsdevelopment, the peculiarities of occlusion, teeth quantity, their character (milk(deciduous, baby, first, primary, temporary) teeth, permanent (succedaneous) teeth); thechest form (conical, cylindric, flat) and its form (Harrison’s trench, keeled chest, funnel
breast, barrel (emphysematous) chest, cardiac hump, one side flattening or one sideoutpouching); the backbone form (the pathological kyphosis presence, lordosis, scolioticangulation) and child’s pelvis (plano- rachitic, Otto’s pelvis); extremities configuration(acromegalia, bradydaktylia, adactylia, aphalangia, etc.); the joints form (edema,deformation), their mobility and the skin and surronding tissues state (eruption presence,knots and other formations); muscles trophism (weak, middle and best state ofdevelopment, atrophy, hypertrophy, hypotrophy); the state of muscles tonus (hypo tonusand hyper tonus). By means of musculoskeletal system palpation the wholeness of skull bones,sutures state and crown is detected (craniotabes, crown sides pliability, crown’s size); thebreaks and deformation presence; osteoid tissue hyperplasia signs (rickety thickening ofwrists and ankles, rachitic rosaries, “beads”); the skin temperature over the joints, pain inbones, muscles and joints; the muscles power and tonus; the infiltration presence. The muscles trophism and power finding out. The muscles trophism which characterises the level of exchange (metabolism)processes is detected by the degree and symmetry of the development of certain musclesgroups. The evaluation is made in the state of calm and in the state of physical loading.The following development states are distinguished: low, middle, good. In case of a lowbody and extremeties muscles development they are not well exposed in the state ofcalm, in case of physical loading their volume is not significanly changed, the lower partof stomach is drooping, the shoulder-blades lower corners are separated from the chest. In case of a middle development, the body muscles mass is moderately exposedin the state of calm, the same of extremities are well exposed, their volume andform arechanged when physically loaded. In case of a good state of development the body andextremities muscles are well developed, and their relief enlargement is visually noticedwhen physically loaded. The muscles power evaluation is made according to the special scale by 5points’ system: 0 points – movements are absent; 1 point – active mopvements areabsent, but muscular tension is detected by means of palpation; 2 points – passivemovements are possible in case of slight resistance overcoming; 4 points – passive
movements are possible in case of moderate resistance overcoming; 5 points – themuscles power is within the normal indexes. Additional methods of investigation: a) calcium, phosphorus, alkalinephosphatase content finding out in blood serum; b) X-ray examination of cells; c)electromyography; d) chronaximetry; e) for eldery children the dynamometry; f) musclesbiopsy; g) densitometry. Osteoid tissue hyperplasia signs Rickety thickening of wrists and ankles, rachitic rosaries, “beads”, frontal tubersenlargement. Osteomalacia signs Craniotabes (occipital bone’s softening), Краніатабес (пом’якшенняпотиличної кістки), back of the head’s flattening, Harrison’s trench, X-like and O-likeshanks (genu varum). The normal rate of Ca and P in blood serum (Doskin V.A., 1997). Usual calcium in blodd cerum 2,5 – 2,87 milli gram-molecule per liter ммоль/л Ionized calcium 1,25 – 1,37 milli gram-molecule per liter Phosphorus inorganic in blood serum 0,65 – 1,62 milli gram molecule per liter Arthritis symptoms. There is a skin oedema, it aches: edemas of the surrounding tissues near joints,the mobility is limited in joints as well as the active movements are also limited. Muscles tonus violation types. Hypotonia – is the muscles tonus lowering (as the result of rachits, hypotrophy,chorea, congenital acromicria (trisomy 21 (Downs) syndrome, mongolism, Downsdisease), hypothyroidism, Hoffmanns muscular atrophy, peripheral paralysis).
Hypertension – the muscles tonus increasing (it is typical for the sound child forthe first 3-4 months of life, central paralysis, meningitis, correcting). Muscles trophism violation types. Atrophy – is the muscles extreme degree of the low development orundevelopment (simple form) or degeneration (degenerative form). The simple form is met in cases of cerebral palsy, muscles diseases (musclesprogressive dystrophy, inborn myodystrophy) and joints (juvenile rheumatoid arthritis,tuberculous coxitis). Degenerative form is the result of peripheral paralysis,poliomyelitis, and others. Hypertrophy – is the process of muscles thickening and mass enlargement. Mostfrequently is found among children going infor sports or practicing physical labour. Incase of pseudohypertrophy fat accumulation simulates the well exposed muscles. Tests:1. The big parietal region of a sound child is closed at the age of: 1.1. 4 - 6 months 1.2. 6 - 8 months 1.3. 9 - 11 months 1.4. 1 - 1,5 years2. The newborn’s chest is of the following form: 2.1. Cylindrical 2.2. Barrel 2.3. Funnel 2.4. Conical3. Which of the given below symptoms is not the sign of rachitis? 3.1. Craniotabes 3.2. Crown sides pliability 3.3. Rachitic rosaries 3.4. Bandy (boomerang) legs4. Which of the given below signs is not the evidence of osteomalacia?
4.1. Craniotabes 4.2. Caput quadratum 4.3. Genu varum 4.4. Back of the head’s flattening5. Which of the given below symptoms is not the sign of osteoid tissue hyperplasia? 5.1. Rachitic rosaries 5.2. Rickety thickening of wrists and ankles 5.3. Harrison’s trench 5.4. Frontal tubers enlargement6. Flat feet is the physiological state for children up to the age of: 6.1. Before 6 months 6.2 First 2-3 years of life 6.3. Up to 5 years 6.4. Up to 7 years7. Physiological chest kyphosis is formed for : 7.1. 2 - 3 months 7.2. 6 - 7 months 7.3. 10 - 12 months 7.4. 1,5 - 2 years8. The flexors hypertonus of the upper extremities is preserved for children up to: 8.1. 1 month 8.2. 2 - 3 months 8.3. 3 - 4 months 8.4. 4 - 5 months9. The flexors hypertonus of the lower extremities disappears at the age of: 9.1. 1 month 9.2. 2 - 3 months 9.3. 3 - 4 months 9.4. 4 - 5 months10.Which of the given below additional methods is used for the muscular systeminvestigation?