Case Files 37-42 (C) Flashcards
Explain antalgic gait
Occurs when the “stance phase” of gait is shortened, usually because of pain during weight bearing
Remember: normal gait consists of two phases (swing and stance, with stance accounting for ~60% of the cycle)
The most common nontraumatic hip pathology in adolescents
Slipped Capital Femoral Epiphysis (SCFE)
Hip pathology will frequently present with pain in the…
groin, thigh, and knee
Pain with internal rotation of the hip
+
External rotation on passive flexion
SCFE
What is the most sensitive mark (on PE) of hip pathology in children
Restricted internal rotation followed by a lack of abduction
The FABER test can find pathology located in the…
SI joint
Fever greater than ___ and ESR gerater than ___ is 97% sensitive for septic hip joint
Fever > 99.5
ESR > 20
Monoarticular with systemic signs (eg, fever)
Think septic arthritis
Children with septic hip joint will often lay with their hip flexed, abducted, and externally rotated
What are the most common pathogens involved in children with septic hip?
< 4 months: GBS and Staph aureus
4 months - 5 years: Staph aureus and Strep pyogenes
Spiral fracture of the tibia that results from twisting while the foot is planted
Toddler’s fracture
Setting = acute limp or change in ambulation
*If the child had a painless limp from the time they learned to walk think congenital dysplasia
Transient synovitis
A self-limited inflammatory response that often follows a viral infection, leading to hip pain in children ages 3-10
Low-grade to no fever, normal WBC, normal ESR
Kocher criteria
Used to assess risk for septic arthritis in children
Four criteria:
- Fever > 101.3
- Nonweight bearing
- ESR > 40
- WBC > 12,00
Purulent aspirate with WBC > 50,000
vs
Yellow/clear aspirate with WBC <10,000
Septic joint
vs
Transient synovitis
Avascular necrosis of the femoral head
AKA Legg-Calvé-Perthes (LCP)
More common in boys than girls
Although any disruption of blood flow to the femoral capital epiphysis, such as trauma or infection, can cause avascular necrosis the etiology of LCP is unknown
Capital Femoral Epiphysis
Growth plate that connects the metaphysis (femoral head) to the diaphysis (shaft of the femur)
Treatment for SCFE
Surgical pinning (do not let them walk after making diagnosis)
33% will develop avascular necrosis and 33% will develop SCFE in the contralateral hip
Pain that wakens a child at night
Suspicious for malignancy
“Growing pains” is a diagnosis of exclusion (it should be considered if the pain is only at night, is bilateral, and if no other pathology is found)
A 6-year-old young boy is brought in for evaluation of a painful hip. He has been limping and not wanting to walk for the past 2 days. He has had no obvious injury. He feels better after taking ibuprofen. He has not had a fever, although he had “the flu” last week. Vitals are normal. Some pain with internal rotation. He walks with a pronounced limp. Can he be sent home?
After getting a CBC and ESR
If they are in normal limits he likely has transient synovitis and can be treated with an NSAID with the expectation of a recovery in a few days
A 6-year-old boy has a 2-month history of slight limp. No PMHx and no medications. Normal vitals, but an antalgic gait and decreased ROM in the L hip (internal). Mild pain on palpation of the anterior capsule on the L side. X-ray shows fragmentation of the femoral head. What is the most likely diagnosis?
Legg-Calvé-Perthes disease
Often a self-healing disorder. Treatment is focused on limiting pain and avoiding functional loss.
Physical exam findings of suprapubic pain and costovertebral tenderness
Suggestive of UTI and most likely acute pyelonephritis
Most common organisms leading to UTIs
E coli
Proteus
Klebsiella
Staph epidermidis
Pseudomonas
Candida
Drugs that are commonly associated with “drug fever”
B-lactams
Sulfa derivatives
Anticonvulsants
Allopurinol
Heparin
Amphotericin B
A rare AD disorder charaterized by fever > 104, tachycardia, metabolic acidosis, rhabdomyolysis, and calcium accumulation in skeletal muscle leading to rigidity
Malignant Hyperthermia
May occur up to 24 hrs after exposure to anesthetic agents such as halothane and succinylcholine
Treatment: discontinue offending agents, supportive therapy (antipyretics, oxygen hyperventilation, cooling blankets, sodium bicarbonate, and dantrolene IV)
Most common postoperative complication
Fever
5 W’s of post-op fever
Wind (pneumonia)
Water (UTI)
Walk (DVT)
Wound (SSI)
Wonder where/drugs (Abscess or Fever)
Causes of immediate postoperative period
Medications
Blood products
Malignant Hyperthermia
Bacteremia
If fever occurs within 36 hours post-laparotomy what two important infectious etiologies should you consider?
Bowel injury with leakage of gastrointestinal contents
Invasive soft-tissue wound infection (caused by β-hemolytic streptococci or Clostridium species)
*Toxic Shock Syndrome caused by Staph aureus is a rare condition
Postoperative pneumonia is typically caused by
polymicrobial
Enterobacteriaceae and S aureus or Enterobacteriaceae and Streptococci
When and which type of antibiotics do you give for aspiration penumonia?
Antibiotics are typically given following a witnessed aspiration and discontinued after 48-72 hours with no development of infiltrates
Gram (-) coverage is required, with the current choice being piperacillin/tazobactam or ticarcillin/clavulanate
Homan sign
Pain in the calf on foot dorsiflexion = DVT
Fever caused by DCT usually occurs on the 5th postoperative day
Stridor vs Wheezing
Stridor: wheezing coming from obstruction of the large airway that has a constant pitch and intensity throughout the entire inspiratory effort
Wheezing: a musical sound heard on pulmonary ausculatation produced by the oscillating walls of airways that had been narrowed by mucus, inflammation, and so on
Extra-thoracic vs Intraluminal Obstruction
Acute wheezing in children
Infectious (eg, bronchiolitis)
or
Mechanical obstruction (eg, FBAO)
Recurrent wheezing in children
Bronchomalacia
CV disease (eg, vascular rings and slings)
GERD
Immunologic disorders (eg, bronchopulmonary dysplasia, cystic fibrosis)
Viral infection cuasing nonspecific inflammation of the small airways, peaking during the winter months
Bronchiolitis
RSV accounts for 70% of cases (rest are caused by parainfluenza, adenovirus, influenza, Mycoplasma pneumonia, Chlamydia pneumonia, and metapneumovirus)
Treatment for bronchiolitis
Supplemental oxygen if SpO2 < 90% and supportive care (clear evidence of effectiveness in RSV bronchiolitis)
Supportive care = supplemental humidified oxygen, fluids, and suctioning
What preventative therapy can be given for children < 2 with increased risks for chronic lung disease, history of prematurity, or with congenital heart disease?
RSV immunoglobulin (RespiGam)
and
Palivizumab (Synagis)
Most common cause of airway obstruction in children aged 6 months to 6 years
Also the leading cause of hospitalization for children younger than 4 years
Croup
Viral infection that causes inflammation of the subglottic region of the larynx
Croup syndrome encompasses: laryngotracheitis, laryngotracheobronchitis, laryngotracheobronchopneumonitis, and spasmodic croup
Croup is caused by…
The parainfluenza viruses (I, II, III) are responsible for 80% of croup cases, with parainfluenza I accounting for most episodes and 50-70% of hospitalizations
Other causes: adenovirus, reovirus, metapneumovirus, varicella, herpes simplex virus, human bocavirus, coronavirus, and influenza A and B
Frontal neck x-rays shows a “steeple sign”
Croup
Indicative of subglottic narrowing of the tracheal lumen
Bacterial infection of the supraglottic tissue
Epiglottitis
Management of a patient with suspected epiglottitis
Take to the OR
Confirm diagnosis with experienced surgeon and anesthesiologist in the room (airway)
Thumb sign on X-ray
Lubiprostone (Amitiza)
Selectively activates intestinal chloride channels and increases fluid secretion
FDA approved for IBS in women with constipation
IBS affects women _____ more times than men
2-3
Rome criteria for IBS
Recurrent abdominal pain at least 3 days per month for the past 3 months, associated with 2 or more of the following:
- improvement with defecation
- onset associated with a change in stool frequency
- onset associated with a change in stool consistency
Treatment for IBS
Abdominal pain: dicyclomine and hyoscyamine (antispasmodics)
Constipation: fiber (psyllium) and fluid, lubiprostone
Diarrhea: loperamide, alosetron
Why is it dangerous to use cocaine and alcohol
Can lead to the formation of cocaethylene, which intensifies cocaine’s effects
Cocaethylene is associated with a greater risk of coronary vasospasm than cocaine alone, resulting in MI and sudden death
True/False: genetic susceptibility accounts for 40-60% of a person’s vulnerability to addiction
True
Barbiturates
Benzodiazepines
GHB
Methaqualone
Depressents
Barbiturates can have a life-threatening withdrawal
Amphetamines
Cocaine
MDMA
Methamphetamine
Methylphenidate
Nicotine
Stimulants
Treatment for opiod withdrawal
Methadone
Buprenorphine
Naltrexone
Nalaxone (IV opioid antagonist) = treatment of choice for acute opoid intoxication
Treatment of nicotine withdrawal
Gum, patch, spray, lazenges
Bupropion
Vareniciline
Common treatment of alcohol withdrawal
Naltrexone
Disulfiram
Acamprosate
*Evidence has found naltrexone/acamprosate to be the most effective treatment of alcohol dependence when used in conjunction with behavioral therapy
MORPHINE-ABC
Mnemonic for signs and symptoms
Miosis, Out of it, Respiratory depression, Pneumonia, Hypotension, Infrequency (constipation/urinary retention), Nausea, Emesis, Analgesic, Bradycardia, Coma
Midsystolic click +/- late systolic murmur
Mitral Valve Prolapse
Most common valvular heart defect in the US
Wolff-Parkinson-White syndrome
Caused by an accessory track between the atria and the ventricles that conducts electrical impulses in addition to the AV node
Classic ECG finding = slurring on the upstroke of the QRS complex (aka delta wave)
Long QT Syndrome
caused by mutations in multiple genes and can have an autosomal dominant pattern
seen more commonly in females
any patient with a QT interval greater than 500 msec is at increased risk for dangerous dysrhythmias
Most common cause of sudden cardiac death in adolescents in the US
Hypertrophic cardiomyopathy
Heart murmur, if present, will usually be systolic and will be accentuated by Valsalva maneuver
What is the most common cause of palpitations
Primary rhythm disturbance (40% of cases)
