Well-Care of Children Clinical Case 1 PDF

AZERBAIJAN MEDICAL UNIVERSITY FAMILY MEDICINE DEPARTMENT Care of children Clinical case Ph.D. Dr. Aygun Guliyeva  CASE 1  A 14-year-old boy presents to your office with a mildly pruritic rash that invo...

AZERBAIJAN MEDICAL UNIVERSITY FAMILY MEDICINE DEPARTMENT Care of children Clinical case Ph.D. Dr. Aygun Guliyeva  CASE 1  A 14-year-old boy presents to your office with a mildly pruritic rash that involves his chest and back. He reports it began with a single lesion on his back, but now has spread to involve his entire back and chest. You note on your examination the presence of multiple secondary lesions that appear to follow cleavage lines. The most likely diagnosis is A) Herpes zoster B) Pityriasis rosea C) Tinea versicolor D) Varicella E) Rhus dermatitis  CASE 1 Answer and Discussion  The answer is B. Pityriasis rosea typically occurs in children and young adults. It is characterized by an initial herald patch, followed by the development of a diffuse papulosquamous rash. Pityriasis rosea is easier to identify when the general eruption appears with smaller secondary lesions that follow Langer’s lines (cleavage lines) in a “Christmas treelike pattern.” Many diseases can mimic pityriasis rosea including drug exanthems, but the most worrisome condition to be ruled out is secondary syphilis. Topical or systemic steroids and antihistamines are often used to relieve itching. Asymptomatic lesions do not require treatment.  Pityriasis rosea is characterized by an initial herald patch, followed by the development of a diffuse papulosquamous rash. Pityriasis rosea  CASE 2  A 5-year-old presents to your office complaining of scrotal pain and you note swelling of the left testis. Appropriate management at this time includes A) Continued observation B) Elevation of the scrotum and ice therapy C) Ultrasound evaluation with Doppler color flow D) Doppler stethoscope evaluation E) Computed tomography (CT) scan of the pelvis  CASE 2 Answer and Discussion  The answer is C. Testicular torsion should be suspected in patients who complain of acute scrotal pain and swelling. Testicular viability is in jeopardy with delay in diagnosis, ultimately impacting the patient fertility. Associated conditions that may resemble testicular torsion not warranting surgery are torsion of a testicular appendage, epididymitis/orchitis, trauma, incarcerated hernia, varicocele, and idiopathic scrotal edema. Testicular torsion is most common in men younger than 25 years old, although it can occur in men of any age. A prepubertal or young male adult with acute scrotal pain should be diagnosed as testicular torsion until proven otherwise. Physical exam finding of higher testicular lie and absent cremasteric reflex are supportive evidence for this condition. Scrotal imaging with Doppler color flow ultrasound is necessary when the diagnosis remains unclear. Once the correct diagnosis is established, prompt surgical evaluation should be performed. It is reasonable to perform manual detorsion for immediate noninvasive treatment followed by elective orchiopexy. Testicular torsion  CASE 3  An 8-year-old is seen in the emergency room secondary to abdominal pain. Further evaluation confirms the presence of intussusception. The most likely precipitating cause is A) Colon polyp B) Meckel’s diverticulum C) Lymphoma D) Parasite infection E) Foreign body  CASE 3 Answer and Discussion  The answer is C. In children older than 6 years, lymphoma is the most common cause. Intussusception is the most common cause of intestinal obstruction in the first 2 years of life. It is more common in boys than in girls. In most cases (85%), the cause is not apparent. Associated conditions that can result in intussusception include polyps, Meckel’s diverticulum, Henoch–Schonlein purpura, lymphoma, lipoma, parasites, foreign bodies, and viral enteritis with hypertrophy of Peyer patches. Intussusception of the small intestine occurs in patients with celiac disease and cystic fibrosis related to the bulk of stool in the terminal ileum. Henoch–Schonlein purpura may also cause isolated small-bowel intussusception. Intermittent smallbowel intussusception is a rare cause of recurrent abdominal pain.  CASE 4  A 12-year-old obese boy presents to your office complaining of bilateral leg pain that occurs only at night. His mother denies any pain during the day and reports he has not had a limp. The most likely diagnosis is A) Slipped capital femoral epiphysis B) Legg–Calve–Perthes disease C) Osgood–Schlatter’s disease D) Patellofemoral syndrome E) “Growing pains”  CASE 4 Answer and Discussion  The answer is E. A diagnosis of “growing pains” must meet three criteria: (1) the leg pain is bilateral; (2) the pain occurs only at night; and (3) the patient has no limp, pain, or symptoms during the day. To inaccurately diagnose a limping child with growing pains can be dangerous, as the physician risks missing the underlying pathology. However, if a child does fit the criteria for growing pains, the parents should be reassured that this is a benign, self- limited process that occurs for unknown reasons. Growing pains  CASE 5  A 12-year-old boy is brought in to your office by his mother and father. The child has been experiencing swelling of his joints, fevers, and a rash. An examination reveals hepatosplenomegaly and lymphadenopathy. Laboratory evaluation shows anemia, leukocytosis, and thrombocytosis. You suspect juvenile rheumatoid arthritis (JRA). Which of the following medications would be first-line treatment? A) Acetaminophen B) Ibuprofen C) Codeine D) Methotrexate E) Prednisone  CASE 5 Answer and Discussion  The answer is B. JRA, formerly known as Still’s disease, is a diverse group of diseases that is clinically distinct from adult rheumatoid arthritis. Most children with JRA have long remissions without loss of function or significant residual deformity. There are no specific laboratory tests to diagnose JRA. One must exclude other causes for arthritis, including reactive arthritis from extra-articular infection, septic arthritis, neoplastic disorders, endocrine disorders (e.g., thyroid disease, type 1 diabetes mellitus), degenerative or mechanical disorders, or idiopathic pediatric joint pain. Diagnosis of JRA requires signs of inflammation rather than simply arthralgias persisting for more than 6 weeks, with onset before age 16 years. JRA has three major subtypes: pauciarticular (40% to 50%), polyarticular (25% to 40%), and systemic (10% to 20%). Each type has different clinical presentations and courses, and treatment is determined by differentiating among the various types. Pauciarticular JRA involves four or fewer joints, usually large joints asymmetrically. Early-onset pauciarticular JRA affects mostly girls younger than 4 years and has a 30% risk of chronic iridocyclitis and a 10% risk of ocular damage. Late-onset pauciarticular JRA affects mostly boys older than 8 years; many of whom later develop spondyloarthropathies; 10% develop iridocyclitis. Slit-lamp ophthalmic examinations are recommended. Polyarticular JRA is defined as arthritis in five or more joints; patients are either RF positive or RF negative. RF positive patients usually are girls aged 8 years or older, have symmetric small-joint arthritis, and have a worse prognosis than do RF-negative patients. Systemic-onset JRA is characterized by high intermittent fevers (>102°F), rash, hepatosplenomegaly, lymphadenopathy, arthralgias, pericarditis, pleuritis, and growth delay. Anemia, leukocytosis, and thrombocytosis are common laboratory findings. Extra-articular symptoms are usually mild and self- limited. Boys and girls are equally affected. NSAIDs are the first-line treatment for JRA. Clinical improvement may not be seen for up to 1 month. Methotrexate is often used with NSAIDs, particularly for systemic and polyarticular JRA. Corticosteroids are used orally for severe, life-threatening, systemic JRA and intra-articularly for pauciarticular JRA. Most children with JRA require a great deal of physical as well as psychological support. Physical and occupational therapy is important because children often stop using painful joints, adding to disability.  CASE 6  An asthmatic 8-year-old is complaining of wheezing and shortness of breath in your office. An albuterol nebulizer treatment is given, and the child’s peak expiratory flow rate (PEFR) is measured at 75%. The appropriate next step would be A) Add an oral steroid B) Add theophylline C) Add ipratropium D) Administer epinephrine  CASE 6 Answer and Discussion  The answer is A. Early treatment of asthma exacerbations is important to prevent progression to severe disease. First-line treatment should be with a short-acting inhaled β2-agonist such as albuterol; two to four puffs from a metered-dose inhaler can be given every 20 minutes up to three times, or a single treatment can be given by nebulizer. If the response is acceptable as assessed by sustained symptom relief or improvement in PEFR to more than 80% of the child’s best, the short-acting β2-agonist can be continued every 3 to 4 hours for 24 to 48 hours. For patients taking inhaled corticosteroids, the dose may be doubled for 7 to 10 days. If the child does not completely improve from the initial therapy, with PEFR between 50% and 80%, the β2agonist should be continued, and an oral corticosteroid should be added. If the child experiences marked distress or if PEFR persists below 50%, the patient should repeat the β2-agonist immediately. Further emergent treatment may be necessary.  CASE 7  An 18-month-old female child presents to your office with her mother. A urinary tract infection (UTI) is discovered. Appropriate treatment at this time including antibiotic coverage includes A) Intravenous pyelogram B) Cystoscopy C) Renal ultrasound and voiding cysturethrography (VCUG) D) Observation with no further testing  CASE 7 Answer and Discussion  The answer is C. Practice guidelines from the American Academy of Pediatrics (AAP) recommend renal ultrasonography in all children 2 months to 2 years of age with a documented first UTI. VCUG is no longer routinely recommended. VCUG is warranted if renal and bladder sonogram reveal hydronephrosis, scarring, presence of findings suggestive of high-grade vesicoureteral reflux (VUR) or obstructive uropathy, or clinical scenarious considered to be complex or atypical. After the age of 2 years, some controversy exists. Some authorities recommend postponing workup for the first UTI in girls.  Practice guidelines from the AAP recommend renal ultrasonography to screen for anatoming abnormalities in all children 2 months to 2 years of age with a documented first UTI.  CASE 8  A 13-year-old girl is brought to your office by her mother. The child has experienced a recent sore throat with fevers and is now complaining of bilateral knee pain. Laboratory evaluation shows an elevated sedimentation rate. The most likely diagnosis is A) JRA B) Acute rheumatic fever C) Lyme’s disease D) Osgood–Schlatter disease E) Patellofemoral syndrome  CASE 8 Answer and Discussion  The answer is B. Rheumatic fever is complication of acute group A streptococcal pharyngitis that presents as an acute systemic febrile illness. Associated findings include a migratory arthritis involving the large joints, signs and symptoms of carditis and valvulitis, the erythema marginatum rash, subcutaneous nodules, and choreoathetotic movements of Sydenham’s chorea. Damage to the cardiac valves may be chronic and progressive, resulting in significant cardiac dysfunction. Although the Modified Jones Criteria help with the clinical diagnosis, no specific symptoms, clinical signs, or laboratory tests are pathognomonic for rheumatic fever. Additionally, not all patients with rheumatic fever fulfill the Modified Jones Criteria. The criteria consist of major manifestations that include carditis, erythema marginatum, polyarthritis, subcutaneous nodules, and Sydenham’s chorea. Minor manifestations include clinical (e.g., arthralgia, fever) and laboratory (e.g., elevated C-reactive protein and erythrocyte sedimentation rate, prolonged PR interval on electrocardiograph) findings. A diagnosis of rheumatic fever is supported by evidence of preceding group A streptococcal infection (i.e., positive throat culture or rapid streptoccocal antigen test, elevated or rising antistreptolysin titer), and the presence of two major manifestations or of one major and two minor manifestations.  CASE 8 Answer and Discussion  Arthritis is the most frequent and least specific manifestation of rheumatic fever. It usually affects the large joints and may be the first sign of illness. The lower extremities generally are affected first, followed by the upper extremities. Joint involvement occurs early in the illness and is more common and severe in younger patients. The arthritis may be painful, but it is transient; the inflammation lasts about 2 to 3 days in each joint and 2 to 3 weeks in total. Radiographic evaluation can show slight joint effusions but usually the results are normal. The arthritis is self-limited, resolves without complications, and is treated with salicylates and NSAIDs. Carditis associated with rheumatic fever presents as pericarditis, myocarditis, and, most commonly, endocarditis. Pericarditis can present with chest discomfort, pleuritic chest pain, pericardial friction rubs, and distant heart sounds. Myocarditis is rare in isolation and can present with signs and symptoms of heart failure. Endocarditis may be asymptomatic or present with a new heart murmur. Cardiac murmurs do not always indicate valvular involvement, and they may be transient.  CASE 8 Answer and Discussion  If valvular disease occurs, it is 455most likely in the mitral, aortic, tricuspid, or pulmonary valve, in that order. Electrocardiograph and echocardiogam abnormalities may be present in about one-third of patients with carditis. Rheumatic heart disease is an important long-term consequence of rheumatic fever and is the major cause of acquired valvular disease internationally. Rheumatic heart disease typically occurs 10 to 20 years after the original rheumatic fever episode. Significant mitral stenosis can occur and require surgery. Sydenham’s chorea is characterized by involuntary movements, muscular weakness, and emotional disturbances. It is usually more marked on one side of the body than the other and may be completely unilateral. Atypical behavior such as crying and restlessness are seen and, in rare cases, features of a psychosis may be noted. There is no sensory loss or involvement of the pyramidal tracts. Sydenham’s chorea is typically self- limited and occurs in 5 mg/dL (86 µmol/L) per day or is >17 mg/dL (290 µmol/L), or an infant has signs and symptoms suggestive of serious illness. The management consists of excluding pathologic causes of hyperbilirubinemia and initiating treatment to prevent harmful neurotoxicity. Phototherapy  CASE 11  A 12-year-old boy presents to your office complaining of gradually increasing hip pain that radiates to the thigh and knee. Physical examination shows an obese boy with pain associated with hip abduction and adduction. Radiographs show evidence of acetabular dysplasia. The most likely diagnosis is A) Congenital dislocation of the hip B) Osgood–Schlatter disease C) Slipped capital femoral epiphyses D) Sacral insufficiency fracture E) Transient synovitis of the hip  CASE 10 Answer and Discussion  The answer is C. Slipped capital femoral epiphyses are usually seen in overweight boys between 11 and 14 years of age. The condition occurs when the femoral head slips posteriorly and inferiorly, exposing the anterior and superior aspects of the metaphysis of the femoral neck. When the condition occurs before puberty, an underlying endocrine disorder (hypothyroidism, growth hormone deficiency) should be suspected. Symptoms, including pain and a limp, are usually gradual in onset and usually involve the hips or are referred to the thigh or knee. The condition is bilateral in 20% of cases. Radiographs should be performed, including frogleg views. Findings include abnormalities with the femoral head, including acetabular dysplasia. Treatment involves orthopaedic referral with surgical pinning. Complications include avascular necrosis of the hip and erosion of cartilage.  CASE 12  A 4-year-old is brought to your office. The parent complains that the child’s hair is falling out. Closer inspection shows the hair shafts are broken just above the scalp. There are scaly, pruritic, mildly inflamed gray patches, and scrapings of the area show the presence of hyphae. The treatment of choice is A) Topical antifungals B) Oral antifungals C) Topical hydrocortisone cream D) Permethrin cream E) Shave the hair off at the scalp and let it regrow  CASE 12 Answer and Discussion  The answer is B. Tinea capitis is a fungal infection of the scalp that usually affects infants and young children. It is contagious and may become epidemic. It is caused by fungi including Trichophyton, Microsporum, and Epidermophyton. Lesions of the scalp usually cause scaly, gray patches that are pruritic. Multiple areas of hair loss may occur with hair shafts broken just above the scalp. Microscopic examination of scrapings after treatment with 10% potassium hydroxide reveals fungal hyphae. Hair examined with black light fluorescences show a greenish-yellow color in cases of microsporosis. Treatment for most tinea infections involves the use of topical antifungals but is not sufficient for tinea capitis, which requires oral administration of antifungals, such as griseofulvin. Severely inflamed lesions benefit from systemic or intralesional steroids. Until tinea capitis is cured, an imidazole or ciclopirox cream should be applied to the scalp to prevent spread, especially to other children, and selenium sulfide 2.5% shampoo should be used daily. Children can attend school during treatment and the risk of transmission is low.  CASE 13  A 2-year-old presents with an erythematous rash on the face (slappedcheek appearance) that has spread to involve the trunk; the extremities are spared. She also has a low-grade fever and malaise. Which of the following is the most likely diagnosis? A) Measles B) Congenital syphilis C) Erythema infectiosum D) Meningococcemia E) Rubeola  CASE 13 Answer and Discussion  The answer is C. Erythema infectiosum is referred to as fifth disease because it represents the fifth major viral childhood illness (which also includes measles, mumps, rubella, and rubeola). The disease is caused by parvovirus B19 and is characterized by mild constitutional symptoms, such as low-grade fever, malaise, and joint pain (particularly in adult women). Also, there is a classic indurated, erythematous maculopapular facial rash that may progress to the trunk and extremities (but spares the palms and soles). The rash is often pronounced on extensor surfaces. The rash is often referred to as a “slapped- cheek” appearance and can be exacerbated with exposure to sunlight, heat, emotional stress, or fever. The illness usually lasts 5 to 10 days, and only symptomatic treatment is necessary. Occasionally, complications include arthropathies, myocarditis, and a transient aplastic crisis. Fifth disease may occasionally cause fetal death secondary to fetal hydrops; therefore, pregnant women should avoid contact with affected patients. Children are not infectious once the rash develops because the rash and arthropathy (when present) are immune-mediated, postinfectious reactions. Therefore, isolation from school and/or day care is not necessary. Erythema infectiosum  CASE 14  A 3-year-old boy presents to your office with a history of seven ear infections over the last year. Appropriate management of this child consists of A) Tonsillectomy and adenoidectomy B) Single-dose prophylactic antibiotics given at night C) Tympanostomy tube placement D) Long-term use of antihistamine-decongestant preparations E) Continued observation  CASE 14 Answer and Discussion  The answer is B. Chronic otitis media usually results from AOM and eustachian tube dysfunction. Despite short courses of antibiotics, affected children have recurrent infections that appear to be more prevalent in the winter months. Persistent chronic otitis media may lead to hearing deficits and subsequent language delays. Prophylaxis should be attempted if the child experiences more than four infections in 1 year or three or more infections within 6 months. Treatment for this difficult problem consists of prophylactic antibiotics given in a single dose at bedtime. Medications for chronic suppression therapy include amoxicillin, sulfisoxazole, or trimethoprim– sulfamethoxazole. If a sulfonamide is used, the child should have a CBC periodically, and parents or guardians should be instructed to discontinue the medication immediately if a rash or mouth sore develops. Steroid use has not been advocated, and myringotomy tube placement should be reserved for children in whom prophylactic therapy fails.  CASE 15  In December, a 4-month-old infant is brought to the emergency room. The parents report the child has had a runny nose, fever, cough, and audible wheezing. The child is attending a day care center, and other children have had similar symptoms. On examination, the child has some rales, wheezing, and intercostal retractions with grunting. The most likely infecting organism is A) S. pneumonia B) H. influenzae C) Adenovirus D) RSV (Respiratory Syncytial Virus) E) Coxsackievirus  CASE 14 Answer and Discussion  The answer is D. RSV is a pneumovirus that usually affects children between 1 and 6 months of age, with a peak incidence at 2 to 3 months of age. The commonly encountered virus gives rise to bronchiolitis and pneumonia. The virus occurs during the winter months and is characterized by rhinorrhea, fever, cough, and wheezing; in more severe cases, tachypnea, dyspnea, and hypoxia are present. The virus is spread by close contacts via fomites and respiratory secretions and tends to occur in outbreaks in places such as day care centers. Physical examination shows nasal flaring, rales, and wheezing as well as intercostal retractions with grunting in infants. Laboratory evaluation usually shows a normal leukocyte count with elevated granulocytes. Chest radiographs may show hyperexpansion, areas of atelectasis, and/or bronchopneumonia. The virus may be quickly detected by immunofluorescence microscopy of nasal swabs or enzymelinked immunoassay antigen detection tests. Treatment of URIs is usually symptomatic. Lower respiratory infections may be treated with supplemental oxygen and hydration. Bronchodilators and corticosteroids are not generally helpful. Aerosolized ribavirin (an antiviral agent) is no longer recommended except in severely immunocompromised patients. Respiratory support may be necessary in severe cases.