Forum Replies Created
-
Posts
-
Hmm… I can’t seem to figure out what I was thinking. Sorry about that. I’ve deleted that fragment…
Revised version:
DISLOCATED SHOULDER
If a prepubertal child presents with a dislocated shoulder, anterior dislocation is MUCH more common than posterior. Obtain an AXILLARY view X-ray.
PEARL: If a prepubertal child presents with what looks like dislocated shoulder, it’s probably NOT A DISLOCATION. It’s actually a FRACTURE.
Great catch. Here’s the updated version:
THYROGLOSSAL DUCT CYST
A thyroglossal duct cyst is a midline lesion on anterior neck. As many as half of all thyroglossal duct cysts can get infected, which then increases the chances of recurrence. Therefore the treatment of choice is surgical excision. For the exam, if they describe a midline cystic lesion, choose this as the diagnosis, and remove it!
PEARL: Don’t get confused with a RANULA: Painless mucous CYSTIC usually near the inner lips or under the tongue. Might be midline. Clear contents. Treated by removal.
Okay great. I’ve added it to the PEARLS section of GBS. Revised version is below:
GUILLAIN-BARRE SYNDROME (GBS, aka ACUTE INFLAMMATORY DEMYELINATING POLYNEUROPATHY or AIDP)
Patients suffering from Guillain-Barre syndrome (GBS, aka acute inflammatory demyelinating polyneuropathy or AIDP) may initially complain of back pain, fever and can have a facial palsy and proximal muscle weakness (trouble rising from chair or shrugging shoulders) prior to lower extremity symptoms. Classically, though, it is an ascending paralysis over several days to weeks in which there is ataxia and then an inability to walk. Look for diminished or absent reflexes in the lower extremities on exam. Sensation is preserved (as is bowel and bladder continence). It can progress to respiratory compromise requiring intubation. Perform a lumbar puncture to look for albuminocytologic dissociation (increased CSF protein in the absence increased WBCs). FYI… they could say there is an absence of pleocytosis (pleocytosis means an increase in WBC’s). For treatment, you can try IVIG or plasmapheresis.
PEARLS: Steroids DO NOT help. Pulse oximetry is a poor indicator of neuromuscular respiratory insufficiency. You can, however, try to obtain a negative inspiratory flow (NIF) or a Forced Vital Capacity (FVC) if the child is old enough to participate with the test (at least 5 years of age). Always keep tick paralysis in your differential, especially if they mention the summer time, a recent vacation, or the woods! Additionally, if someone presents with GBS a few weeks after a diarrheal illness, they might be referring to C. jejuni infection (known antecedent to GBS though mechanism is not understood). Also, when compared to any CORD COMPRESSION SYNDROME, GBS maintains rectal tone, bowel/bladder continence and sensation. It also has decreased reflexes. In cord compression syndromes, sensation, tone and continence are lost, and reflexes are increased.
Good eye. I’ve modified it. Basically just changed A to C and made a small modification to the answer text.
Thanks!
There’s a great UpToDate article about the subject. Also, this page on eMedicine discusses not treating it: http://emedicine.medscape.com/article/967600-overview
Here’s the except:
“Occult bacteremia now occurs in only 1 of 200 children who present with acute fever (temperature of 39o C [102.2o F] or higher) and white blood cell counts of 15,000/µL or higher. The most likely cause of bacteremia remains S pneumoniae; when there is no evidence of toxicity, such bacteremia is generally a benign, self-limited event.
Because of the extremely low yield, blood cultures are no longer routinely warranted in children aged 3-36 months who have no obvious source of infection, and empiric treatment of occult bacteremia is no longer appropriate. Almost all cases will spontaneously resolve with a low rate of subsequent focal infection. If a child remains febrile and worsens clinically, further diagnostic evaluation and possible empiric treatment with antibiotics pending results o cultures may be considered.”
======
I also remember having a case like this that was discussed in great length during residency. UpToDate also discusses a watchful waiting approach for asymptomatic and incidentally found pneumococcal bacteremia. For anyone reading this… STAPH AURESUS bacteremia is always treated. Horrendous mortality so you have to be extra careful. Echo to rule out endocarditis, etc.
Updated occult bacteremia section:
OCCULT BACTEREMIA
Streptococcus pneumoniae (Pneumococcus) is the most common etiology of occult bacteremia (no obvious source). For Streptococcal bacteremia found incidentally, if there are NO symptoms, then you do NOT need to treat!
You are correct sir! I’ve moved it to the ortho section.
New Wegener’s section:
WEGENER’S GRANULOMATOSIS
(Rare in kids, low yield). Wegener’s granulomatosis is a multisystem vasculitis that affects the sinuses, lungs and kidneys. Look for a +C-ANCA (as opposed to the p-ANCA seen in ulcerative colitis).
=============
New Joint Hypermobility section:
JOINT HYPERMOBILITY
A child with joint hypermobility might present with a history of “loose joints.” It sounds good, but these children are actually more prone to getting injured with sprains. The treatment is to encourage stretching!
MNEMONIC/PEARL: They’ll talk about loose JOINTS, not someone being extremely flexible. The stretching stretches the ligaments and makes them less prone to injury as the joints are all loose and sliding all over the place.
Good discussion. You’re absolutely right about it being debatable. I’ve looked at several resources and articles now, and that seems to be the running theme. In general, it’s a disease that often resolves quickly and without any pharmacologic interventions.
I’d say use NSAIDs cautiously for joint pain, especially given the concerns for renal disease associated with HSP. For patients with severe symptoms requiring hospitalization, or GI symptoms that prevent them from eating, use steroids with or without other therapies (i.e., cyclophosphamide, azathioprine, plasmapheresis, IVIG, etc.). Given that it’s a debatable topic, I can “almost” assure you that you would only be asked to give NSAIDS in the absence of renal disease or give steroids for severe symptoms.
Updated version is below:
HENOCH SCHONLEIN PURPURA (HSP)
Henoch Schonlein purpura (HSP) is a vasculitis which can involve multiple systems, including the skin, joints, GI tract and kidneys. Classic findings include PALPABLE and TENDER purpura that blanch. These are most often found at the lower extremities and buttocks, but may be elsewhere. There may also be periarticular joint involvement (soft tissue only) at the knees or ankles, and a faint rash. Patients may initially present with colicky abdominal pain +/- blood in stool +/- intussusception +/- gallbladder hydrops. Skin findings are impressive, but the labs show a normal platelet count. Urinalysis will likely show hematuria +/- proteinuria which can range from mild to nephrotic range (order a spot protein to creatinine ratio). This may be diagnosed on clinical findings. Complement levels can be low. A biopsy may be obtained if there is doubt about the diagnosis. Biopsy would show IgA, IgG and C3 deposits. For treatment, do not give steroid monotherapy because it will not work. The disease often resolves without intervention and the use of medications is debatable, meaning it’s unlikely to be tested. For the boards, give NSAIDS for joint pain in the absence of renal disease, and for severe symptoms (can’t eat) or for a hospitalized patient, give steroids with or without other therapies (i.e., cyclophosphamide, azathioprine, plasmapheresis, IVIG, etc.).
IMAGE: http://bit.ly/nsNXZo
Thanks for the heads up on this VERY high-yield topic bdig.
I’ve rephrased to make it more clear. Also, changed the typo from LESS to MORE. Revised version is below.
JUVENILE RHEUMATOID ARTHRITIS (JRA)
KNOW JUVENILE RHEUMATOID ARTHRITIS WELL! The diagnosis requires knowing quite a few details. The child should have been under the age of 16 at the time of symptom onset. Symptoms must be present for at least 6 WEEKS before the diagnosis can be made. In children, if arthritis is present it is more common in the LARGE joints and rheumatoid nodules are much less common when compared to adults. A positive rheumatoid factor indicates a worse prognosis. Do NOT order a rheumatoid factor for diagnostic purposes. It can help with prognosis/subtyping, but a negative RF does NOT rule out RA.
* OLIGOARTICULAR JRA (OLIGOARTHRITIS): This refers to JRA that affects 4 OR LESS JOINTS, and is the more common type of JRA (>50%). Positive markers (rheumatoid factor and ANA) make this subtype much more likely. It’s more common in younger girls and is associated with chronic uveitis. Since visual complaints may be absent, patients need to have regular eye exams. Boys have a better prognosis.
- MNEMONIC: The O’s for OligO look like EYES and need regular eye exams because it is the more serious subtype.
* POLYARTICUlAR JRA (POLYARTHRITIS): This refers to JRA that affects 5 OR MORE JOINTS. Also more common in young girls. Systemic symptoms outside of the joints is not common.
* SYSTEMIC (aka STILLS DISEASE): This is equally as common in boys and girls. There are many classic symptoms and finding to be aware of including an episodic, salmon-colored “EVANESCENT RASH.” Patients may also have an extremely high LEUKOCYTOSIS (> 30K), with spiking fevers, lymphadenopathy and possible hepatosplenomegaly. Patients may also have pleurisy, pericarditis and the Koebner phenomenon (linear skin lesions appearing along a site of injury, rubbing or scratching). Serum markers are NEGATIVE.
- PEARL: If everything else fits and the patient doesn’t have an arthritis, go ahead and pick this diagnosis! The other symptoms are commonly present well before the arthritis component kicks in.
- PEARL: This can be a difficult diagnosis to make and is often missed in clinical practice and on the pediatric board exam. Please be VERY, VERY comfortable with this topic.
- PEARLS: In comparison to leukemia, pain is in the AM (not at night), pain is in the joints (not the bone), mild hematologic anomalies (not severe), symptoms wax and wane (not persistent/worsening), symptoms are insidious in onset (not acute) and JRA may have a rash. BOTH can have lymphadenopathy and hepatosplenomegaly. In comparison to septic arthritis, remember the insidious onset of symptoms for JRA (not acute).
* TREATMENT: First line treatment = NSAIDS. Second line treatment = STEROIDS.
For this topic, it really depends on where you look. UpToDate has a VERY comprehensive discussion, but it’s too difficult to simplify. The American Academy of Neurology is currently working on a new set of guidelines, but still refers physicians to their 1997 guidelines – http://www.aan.com/professionals/practice/guidelines/pda/Concussion_sports.pdf
For now, I’m fairly comfortable with the way I’ve written it. I think it’s a good way to evaluate “ABP patients” and will likely lead you to the correct answer. Here is the section again, no changes made:
POST CONCUSSION TREATMENT
Post concussion treatment varies depending on whether there was loss of consciousness and/or amnesia:
* GRADE 1: NO LOC + NO amnesia + Confusion. Reevaluate every 5 minutes for neurologic changes. May return to sports if mentation is clear and there are no symptoms for 20 minutes.
* GRADE 2: NO LOC + AMNESIA + Confusion. Patient should have medical follow-up at 24 hours. May return to sports once the patient is asymptomatic for 1 week.
* GRADE 3: LOC + AMNESIA + Confusion. Take these patients to the ER for further evaluation and probable imaging. May return to sports once the patient is asymptomatic for 2 weeks.
- PROGNOSIS: Worse if concussion was associated with amnesia, prolonged confusion, prolonged recovery or repeated trauma.
* IMAGING: Required if loss of consciousness (LOC) > 1 minute, or if there are still neurologic symptoms at presentation in the ER.
* MNEMONIC: Instead of “LOC,” think “LAC” for the 3 differentiating factors (LOC, Amnesia and Confusion). Grades 1 through 3 add one finding per grade, and they happen to go in the reverse order of C-A-L (Gr 1 = Confusion, Gr 2 = Confusion and Amnesia, Gr 3 = Confusion, Amnesia and LOC). Regarding timings for return to play, they are 0 weeks, 1 week and then 2 weeks of symptom-free time.
You’re right. Thanks for the catch. Here’s the updated section:
CARDIOPULMONARY RESUSCITATION (CPR)
Cardiopulmonary Resuscitation (CPR) is a low-yield topic because guidelines are always changing.
* SINGLE RESCUER CPR FOR BABIES: Provide compressions and breaths at a ratio of 30:2 to minimize transition times. Also, COMPRESSIONS are more important than breaths.
* DOUBLE RESCUER CPR FOR BABIES: Provide compressions and breaths at a ratio of 15:1 (15 compressions for every breath).
* ADOLESCENTS: 30:2 regardless of the number of rescuers.
* PEARL: Guidelines have changed, but the key is to remember that it’s becoming more and more important to focus on high quality chest compressions to get the blood flowing rather than focusing on breaths.
Thanks! It looks like the new guidelines came out right before my first print. I’ve made the correction. Here’s the update, and a good resource – http://www.cdc.gov/motorvehiclesafety/child_passenger_safety/cps-factsheet.html
AUTOMOBILE AND CAR SEAT SAFETY
Automobile and car seat safety guidelines vary depending on a child’s age and weight.
* REAR-FACING CAR SEAT: From birth to 24 months of age, infants should be seated in the back seat at a 45-degree angle. They should be seated in the middle and face the rear of the car. This should be continued until the child is over 24 months or until they outgrow the manufacturer’s weight and height limits. After that, the car seat may face forward.
* FORWARD FACING CAR SEAT: When they graduate from the rear-facing seat, they can be in a front-facing car seat with a harness until they again outgrow the manufacturer’s weight and height limits (usually around 4 years of age).
* BOOSTER SEAT: Around 4 years of age or 40 lbs, kids outgrow the car seat and will need a belt-positioned booster seat. They stay in that until a regular seatbelt fits.
* SEATBELT: Children may use a regular seatbelt, while still sitting in the back seat, once it fits properly. Usually when they reach 4 feet 9 inches around the ages of 8 – 12.
* FRONT SEAT: Children may sit in the front seat once they become teenagers (regardless of weight).
Thanks bdig.
While it’s still used, it seems to have fallen out of favor as a first-line agent. Methimazole seems to have stepped up to the plate. Love the mnemonic… I’m assuming it’s yours and I’m going to use it! Here’s the updated version:
GRAVES DISEASE = HYPERthyroidism
Graves disease (aka Grave’s Disease) causes hyperthyroidism due to the presence of “thyroid-stimulating immunoglobulin.” Signs/symptoms may include an infiltrative ophthalmopathy, emotional lability, weight loss, heat intolerance and possible LID LAG. TSH should be VERY low/absent! Radioactive Iodine Uptake is HIGH in Grave’s since it needs lots of iodine to make all of the THYROXINE being released. Treatments options include methimazole, iodine ablation, a beta blocker (propranolol for symptomatic relief) and thyroidectomy. Methimazole and PTU inhibit T4 production (not secretion). GOITERS in patients with hyperthyroidism are cells that are FULL of thyroid hormone so it can take months to become euthyroid.
PEARL: Some of the symptoms of hyperthyroidism may be disguised as “hyperactivity, disorganized thinking and trouble sleeping.”
PEARL: If a patient has a goiter, more information is needed to differentiate between hypothyroidism and hyperthyroidism
MNEMONIC: PTU can be quite toxic so it is NOT a first-line agent. P-T-U = Potentially Toxic, UGH!
Yup. There was a type-o, and I think the mnemonic could be stronger. I’m changing it to the following for the next print and online guide. Thanks!
ORNITHINE TRANSCARBAMYLASE DEFICIENCY
In ornithine transcarbamylase deficiency, the serum is completely void of citrulline and arginine because OTC is not catalyzing the reaction needed to make citrulline! This is the most common defect and it’s X-linked. Much more symptomatic in boys than the girl carriers who only get symptoms when they are sick. Look for a HIGH urine Orotic Acid (all of the built up carbamoyl phosphate gets turned into this).
MNEMONICS: For ornithine transcarbamylaX deficiency, think PORNOthine transcarboxylase deficiency (or PORNO THEME transcarboxylase deficiency). Who watches EROTIC (Orotic) movies? Boys! That should remind you that it’s an X-linked disorder. “Erotic” should remind you to look for an elevated OROTIC acid.
Thanks! Luckily the Summary Table is accurate. I’ve modified the two sections in the book for future members. Here it is:
(DOUBLE TAKE) STACCATO, BARKY & PAROXYSMAL COUGHS
* STACCATO: If this term is used to describe an infection-related cough, pick CHLAMYDIA PNEUMONIAE.
* BARKY: If this term is used to describe the cough, pick CROUP. Which is most commonly from parainfluenza and other viruses.
* PAROXYSMAL: If this term is used to describe the cough, pick PERTUSSIS.
Not sure how that happened. I’m guessing lots of people noted it and said, “what’s he on?”
I’ve made the correction. Revised mnemonic is below
AUTOSOMAL RECESSIVE MNEMONIC
This autosomal recessive mnemonic is strange, but easy to remember: “PAT HAS WACK GAS which made me HURL in the BACK SEAT of an AUTOmobile!” If you are unfamiliar with PAT, s/he is unique Saturday Night Live character. Possibly male… possibly female… definitely full of WACK GAS that would make you HURL in the BACK SEAT of an AUTOmobile!
* PAT: http://upload.wikimedia.org/wikipedia/en/9/99/Itispat.jpg
* P = PHENYLKETONURIA (aka PKU)
* A = ALPHA-1-ANTITRYPSIN DEFICIENCY
* T = TAY-SACHS DISEASE
* H & HURL = HURLER’S SYNDROME
* A = ATAXIA TELANGIECTASIA
* S = SICKLE CELL DISEASE and the THALASSEMIAS
* W = WILSONS DISEASE
* A = ALPERS SYNDROME (AKA Progressive Sclerosing Poliodystrophy): This is a progressive neurologic disease. Patients do not meet their milestones and are noted to have ataxia, cognitive deficits and seizures. Also have liver disease. Die by 10 years of age.
- MNEMONIC: The symptoms of ataxia and cognitive deficits are remarkably similar to how you would feel if you got ALTITUDE sickness in the Swiss ALPS!
* C = CYSTIC FIBROSIS
* K = KARTAGENER SYNDROME: = Immotile Celia & Sperm. Lung issues and infertile. “while playing KAR-TAG, atul’s CELICA became immotile”
* G = GALACTOSEMIA
* A = see “A” disorders above
* S = see “S” disorder above
* BACK SEAT = May help you remember that this mnemonic deals with recessive disorders.
* AUTOmobile = AUTOsomal recessive.
