Case Study E4

Question 1

Child admitted with potential oligoarthritis what is the significance if Olga complains of blurred vision ‘floaters’ or photophobia

Answer 1

Big complication is iridocyclitis

Question 2

10 yo admitted with tentative enthesitis what is the significance if he starts complaining of back pain

Answer 2

Potential complication of juvenile ankylosing spondylitis (JAS) where the back is hunched over/curved

Question 3

Polly is seen in the Pediatric clinic for a follow up appointment (polyarticular arthritis). She complains of periodic joint swelling and pain of her knees and ankles. Her mother is concerned that this has led to a decrease in the ROM of these joints, especially when arising in the morning. What is the significance?

Answer 3

Most likely due to gelling, a complication that occurs with decreased movement. Keeping her warm and moving will help, this will be the worst in the morning

Question 4

Stasia is a 4 yo diagnosed with systemic arthritis discharged on a DMARD and ibuprofen a month later the mother calls the clinic and says that she has a fever what are your concerns?

Answer 4

Could be an infection related to the DMARD (it is a cancer med) this needs to be referred since it can cause major complications

Question 5

Ferris, a large 13-year-old, has left knee pain that has developed gradually over the last 4 months while playing basketball. An increase in pain occurred after a game the night before. No specific injury was witnessed. Ferris holds the left leg in external rotation and is unwilling to move it due to pain with movement. Walks with a limp with minimal weight bearing on left. Left side problem No knee swelling bilaterally.
What is this and treatment

Answer 5

Slipped capital Femoral Epiphysis (SCFE) referred knee pain
Shifted growth plate (ice-cream coming off the cone)
Tx: Non weight bearing, no contact sports until 18-20, possible traction but pinning of femoral head is the most common

Question 6

An athletic 14-year-old complains of left knee pain after running during basketball and soccer practices and games. Pain increases with activity and subsides with rest. He has no history of injury. Neither of his knees is swollen however the left proximal tibia is tender to touch.
What is it and treatment

Answer 6

Osgood-Schlatter Disease
Tx. Physical therapy, and rest, ice and compression (NOT elevation)

Question 7

13-year-old complains of right knee pain that occurred after a collision and fall during basketball practice. A popping noise was heard at the time of the injury and he fell and was not able to weight bear. The knee is swollen at the lateral aspect of the knee and is painful at rest with a decreased ROM.
What is it and the treatment

Answer 7

Knee sprain (acl tear) Dx by the anterior drawer test or lachmans test as well as an MRI
Tx: RICE, physical therapy and surgery, patient to wear brace long term

Question 8

7-year-old, was seen 2 weeks ago when it was noted that he walked with a limp at the end of basketball camp. When questioned, Calvin stated that his knee hurt. At that time, physical exam findings of his knee were negative and an X-ray of his knee revealed no pathology. Instructions were to “rest” the knee, administer acetaminophen as needed and return to the clinic if the pain grew worse.
Calvin has now returned to the clinic. He continues to experience knee pain and to walk with a limp.
What is it and treatment

Answer 8

Legg-calve-perthes disease
Progression of disease 1. necrosis 2. fragmentation 3. re-ossification 4. remodeling
Tx: pinning and hip spica

Question 9

8-year-old boy, began complaining of left leg and knee pain three days ago. His mother noticed that he was limping and didn’t want to go outside to play. She was concerned because Austin rarely complains of minor illnesses, though he has sores around his mouth for the last 2 weeks, following summer camp. Austin states “it hurts a lot” and points to his lower left femur and the surrounding area. He doesn’t remember any injury, but might have fallen while using his in-line skates.
His distal left femur is swollen with erythema. Holds left leg in semi-flexion. Guarding of left leg on exam. Pain with palpation of distal left femur. Unwilling to ambulate on painful left leg limp. Decreased range of motion to left hip and left knee. All other joints have normal ROM & strength. Temperature is 101°F.
What is it and treatment

Answer 9

Osteomyelitis (bone infection) likely from tooth abscess, tonsillitis, impetigo or uti
Dx. MRI, bone scans or an aspiration of the marrow
Tx. Resting, splinting, and antibiotics for months, NON-weight bearing

Question 10

14-year-old boy, recently started experiencing pain in his right knee during basketball practice. His leg became increasingly swollen and painful; rest did not bring improvement. Oscar went to a Walk-In clinic and was told that the injury was probably a sprain and to rest, apply ice, apply compression, and elevate (RICE). Return to clinic if no improvement. Oscar’s symptoms did not improve and he is being seen today, a week later. A right leg X-ray was ordered and revealed a tumor mass with a “sunburst” appearance near the right femoral epiphysis.
What is it and treatment

Answer 10

Osterosarcoma (cancer of the bone)
Dx. CBC, CT, MRI, Xray (looking for mets to lungs or other bones) Bone biopsy + enzymes (wil be high in blood)
Tx. surgrey (amputations) and high doses of chemo, radiation does not penetrate bone

Question 11

10 year old, complains of left knee pain of 3 weeks duration since the start of basketball season. No specific injury has occurred. He has been limping for several days, and his mother now notes his left knee is swollen. Jules says that his knee is very stiff when he first gets up in the morning, but seems to improve later in the day. Physical examination shows a definitely swollen left knee with limitation of mobility due to pain and stiffness. The right knee is slightly swollen with full ROM.

Answer 11

Enthesitis

Question 12

You are told by both parents during the initial history that Brian (diagnosed with a medulloblastoma) had been punished several times recently for his clumsiness and accidents. What is your response?

Answer 12

Have empathy, ask how they’re feeling (guilt) and let them vent. Reassure that it is a common thing to do and the important thing is they noticed the pattern and brought the child in for treatment

Question 13

Brian has an elevated temp (101.6º F), within the first 6 hours postoperatively what are the causes. If it is 24 hours post op with a temp what is the cause and what would you assess for?

Answer 13

First 6 hours, likely from anesthesia if over 24 hours likely an infection (meningitis) call immediately and expect antibiotics

Question 14

Nursing assessments are important postop brain surgery in relation to these areas: Dressing, Positioning, Fluids/IO, Eye care

Answer 14

Dressing (watch for any clear drainage) Positioning (no elevated children, keep them flat and midline) Fluids (segars + mannitol for ICP) Eye care (artificial tears)

Question 15

During a follow up visit at the pediatric neurology clinic, Brian (medulloblastoma) has no complaints except for lower back pain. Physical findings are WNL. What is the concern?

Answer 15

Mets to the spinal cord

Question 16

What are the similarities and significant differences between bacterial + viral meningitis assessment findings?

Answer 16

Viral - less sick
Bacterial - Lumbar puncture (higher opening pressure, proteins HIGH glucose LOW) WBC elevated and coagulation studies reflecting DIC (low plts, long PT + PTT)

Question 17

How long are the two meningitis patients in isolation?

Answer 17

Viral - can be out of isolation as soon as its known it is viral
Bacterial - out of isolation after 24 hours on ABX

Question 18

If a resident ordered a NS bolus for s child with meningitis what are your concerns?

Answer 18

Not an expected order, should definitely question, pt is on a fluid restriction (segars) we don’t want to raise the ICP

Question 19

Likely outcomes for viral vs bacterial meningitis

Answer 19

Viral recover within a few weeks
Bacterial more likely to have complications (seizures, stroke, mental complications, DIC, organ failure, arthritis)

Question 20

An 8-month-old girl has been referred for therapy for a possible diagnosis of Cerebral Palsy. Which of the following assessment findings are most likely? Choose all that apply.
A. Persistent Tonic Neck Reflex
B. Hypotonia
C. Clenched fists
D. Difficulty eating solids (pureed)

Answer 20

A (should be gone by now - floppy) C (baby should learn to pick up things by now) D (by 8mo should know how to ear purred foods)

B - by 6 months they would be HYPERTONIC

Question 21

What is the purpose (in pt with neuroblastoma) of the chest X-ray, skeletal survey, bone scan, bone marrow aspiration and liver function tests?

Answer 21

Checking for mets

Question 22

Significance of following physical findings? Abdomen enlarged in RUQ - tender with palpation, Extremity pain, Pale bleeding gums petechiae, proptosis peri-orbital swelling with bruising

Answer 22

Abdomen enlarged in RUQ, tender with palpation - spreading to liver
Extremity pain - mets in the bones
Pale, bleeding gums, ecchymosis & petechiae - in the bone marrow
Proptosis, peri-orbital swelling with bruising - tumor behind/involving the eye

Question 23

Norbert (6mo) has surgery to remove the tumor, followed by chemotherapy. How would Norbert’s treatment have been different if he had been 2 years old or if he had a positive N-myc amplification at the time of diagnosis?

Answer 23

The outcome is not as good, probably would have added radiation and upped the chemo

Question 24

Ivan is a 6-month-old infant with recently diagnosed seizures. His parents have observed that he has stopped smiling as much and seems more irritable. They thought he had “colic.” Their description of the seizures is: He seems to stiffen slightly first, then suddenly “bends” with both his head and legs. He often appears “startled”. His arms are flung out and he cries suddenly. Episode lasts for a short time, but he often has many of them in a row, as many as 10-20 per day. Seems to have them around naps or when he’s tired, but usually stays awake.

Answer 24

Infantile spasms
Dx. EEG Random high voltage slow waves and spikes
Tx. ACTH 2-4 units/kg/day IM daily for 2 wks than taper, ketogenic diet can be helpful

Question 25

Frieda, a 2-month-old is brought to the emergency room because she had a seizure at home. She also felt hot. Currently, her temp is 103°F and she is sleepy. Her parents describe the seizure: She suddenly stiffened, her eyes appeared glazed and then her extremities began to twitch and shake. Has been sleepy since. Parents thought that an aunt had seizures when she was an infant, no other family seizure history. A septic workup is done

Answer 25

Febrile seizure
Tx. Possible tylenol or rectal valium (diastat) to prevent future seizures

Question 26

Anthony is a 4 year old male with a diagnosis of seizures. Parents describe his seizures as sudden episodes where he “loses his grip” and his body falls without warning, sometimes with great force. Episodes are usually brief and are usually in the morning. Usually he remains awake during and after the episode, or loses consciousness only briefly.

Answer 26

Atonic
Dx. EEG typical slow pike wave complexes with high-voltage generalized spikes
Tx. Difficult to treat could use Antiepileptic meds or ACTH/corticosteroids
Ketogenic or medium chain triglyceride diet could be possible
Teaching: pt should wear helmet with chin padding

Question 27

Toni Colette is a 5 year old girl brought to the ER following a seizure at home. Her mother describes the seizure: Seizure was sudden, lasting several minutes, with jerking movements of arms and legs and drooling from the mouth. Toni was very tired after the seizure and went back to sleep after the episode was over and she was incontinent of urine and stool. Paternal uncle has been diagnosed with epilepsy.

Answer 27

Tonic Clonic
EEG symmetric high voltage spikes, waves and mixed patterns
Tx. phenobarbital, dilantin, mysoline, tegretol, depakote (best controlled with combo of drugs)
Sudden loss of muscle movement, aura possible, possible bowel/bladder control

Question 28

Kimball is an eight-year-old with a birth history of prolonged labor with asphyxia. He has been diagnosed with cerebral palsy. His mother describes the seizure: Kimball usually is very agitated immediately preceding the seizure. He has a vague stare, asymmetric facial grimace, and makes throaty sounds with chewing motion. Usually last for several minutes. Afterwards he seems sleepy. Kimball has no memory of the seizure, but does recall a vague metallic taste just preceding the onset of symptoms.

Answer 28

Complex partial seizure: onset varries, may last several minutes, decreased loc, no memory, aura common
EEG - focal spikes + slow waves in temporal lobe
Tx - Dilantin, mysolin or tegretol

Question 29

Abby is a 7 year old female being worked up for possible seizure disorder. Her teacher has noticed her daydreaming frequently through the day. Her parents noticed that she sometimes appears confused, but then she resumes her activities as if nothing happened. Occasionally, eye twitching is noted. These episodes have increased in frequency lately, up to 15 times or more a day. She is typically an average student, but she has had a dramatic increase in incomplete assignments and lower grades lately.

Answer 29

Absense/Petit Mal - Onset school age, brief staring, no falls, no aura, may be confused
EEG: 3 sec bilateral high voltage spikes
Tx: Zarontin, depakene, klonopin
Possible ketogenic diet

Question 30

Eight-year-old Simone has had seizures since being an infant. She was a full term, AGA infant. She contracted herpes shortly after birth which progressed to central nervous system disease, resulting in seizures and severe developmental delay. Her parents describe the seizure: Seizures are brief, lasting less than a minute and occur without warning. Typically she has twitching of her right hand. Simone remains awake during and after a seizure.

Answer 30

Simple partial seizure - onset varies, brief, awake/aware, possible aura
EEG: focal spikes of slow waves in cortical region (top)
Tx: Phenobarbitol, dilantin, mysoline

Question 31

What are the priorities for caring for a tonic clonic seizure?

Answer 31

Prevention of injury before airway (side lying) record timing AFTER identify cause, take vitals and perform a neuro assessment

Question 32

Active seizure meds in home

Answer 32

Rectal diastat (valium) or Buccal/intranasal midazolam (versed)

Question 33

Active seizure ER/inpatient meds

Answer 33

1 ativan (lorazepam)

then vlaium (diazapam/diastat) versed (midazolam)

Question 34

When newly diagnosed with a seizure disorder, what teaching should be done for a child and parent(s) before discharge?

Answer 34

Know which type of seizure the child has and which treatments are available and know rescue medications/how to administer them
Prevent injury before the airway but turn pt on side

Question 35

What are your concerns if a parent (seizure disorder) calls the Pediatric office because their child has developed a rash?

Answer 35

Side effect to meds - rash, liver and GI signs

Question 36

A newborn with myelomeningocele has recently had a surgical repair to close the defect. Which of the following are associated with early symptoms of increased intracranial pressure (IICP)?
Pick all that apply.
A. Temperature 101 F
B. No movement in lower extremities
C. Bulging fontanel
D. High pitch cry
E. Sunset eyes

Answer 36

C. Bulging fontanel increased head circumference

Not
A. Temperature 101 F important complication (possible meningitis peritonitis)
B. No movement in lower extremities sign of spina bifida (not a complication, but expected finding)
D. High pitch cry not an early sign
E. Sunset eyes not an early sign

Question 37

What are the primary symptoms of cerebral palsy

Answer 37

Altered muscle movement - contractures, GERD (prone to infection) alerted vision/hearing/communication, possible seizures
Decreased GI motility, constipation and dental problems
Skin problems consists of rubbing or drooling

Question 38

You are the school nurse. The teacher’s aide who had been with Cedric since he started school will not be returning. Cedric will start school with a new aide who had no previous medical type experience. What will you teach him/her? Differentiate between “need to know” and “nice to know.”

Answer 38

• Resp prone to infection; any resp symptoms bring in; GER (elevate after eating or looks like throughing up)
• Mobility how wheelchair/orthotics works; positioning; depends (changing hard because of stiff legs; don’t use excessive force – use steady pressure to relax joint until it folds otherwise can cause pain or harm)
• Skin watch for breakdown (drooling; rubbing on orthotics/wheelchair)
• Nutrition methods of feeding (what is school plan; G-tube at night; eating as normally as possible – aide instructed on best techniques to feed child)
• Communication maximizing abilities, communicate effectively w/ vocalization and eye blinks (wants/feels/likes)
• Seizures neuro, do not take out of chair (safest there), but record the seizure
• GI/GU constipation or BM
• General dental care (rinsing mouth)

Question 39

Cedric had been discharged from the hospital following a respiratory illness. You are his assigned home health nurse. What physical exam assessments would you likely find?

Answer 39

Should be recovering but may take longer, should be tolerating food, respiratory secretions should decrease (residual crackles in lungs) help him cough and clear

Question 40

Most helpful assessment in determining neuro status in a concussion

Question 41

What are your concerns if a pt with a concussion starts vomiting in the ER

Question 42

What position should a concussion pt be put into after cervical collar is removed

Question 43

Concussion pt has small amount of clear drainage from nose or ears what is your concern?