The presence of purpura must make the nurse practitioner consider platelet problems. Fatigue should prompt consideration of anemia. Both are seen in patients with leukemia. Acute leukemia must be considered because of the combination of fatigue and purpura. This child needs a CBC as soon possible. Kawasaki syndrome is an autoimmune disease that produces vasculitis of the mid-sized arteries. Henoch-Schonlein purpura could also be considered as part of the NP’s differential, but this was not a choice.
In an 8 year-old, there are several diagnoses in the differential. One must consider Legg-Calve Perthes, transient synovitis of the hip, a slipped capital femoral epiphysis (SCFE), and a septic hip. This could be as benign as transient synovitis that does not require referral. All of the others mentioned would need urgent orthopedic referral. Once the diagnostics were completed, the NP would have a better idea about whether orthopedic referral was essential.
In patients with Osgood-Schlatter disease, pain can be unilateral or bilateral. What is obvious on assessment is a swelling of the tibial tubercle. X-rays are not needed for diagnosis. Pain worsens with squatting or crouching and with contraction of the quadriceps muscle against resistance. An avulsion of the quadriceps tendon should be part of the differential for patients who exhibit severe pain.
The Moro reflex is a startle reflex. Observation of the reflex is confirmed if the infant symmetrically flings his arms away from his body followed by an immediate flexion of both arms in response to simulating falling. If this is asymmetrical, it could indicate an injury during or after birth (more likely during birth) such as a brachial plexus palsy, hemiplegia, or even a fractured clavicle. The Moro reflex usually disappears between 3-6 months. The significance of this reflex is for evaluation of integration of the central nervous system.
Neurofibromatosis (NF) is a common neurocutaneous disorder. The most common form is von Recklinghausen’s NF. Approximately 85% of patients with NF have this type. The incidence is about 1 in 2600 individuals. Children with this disorder have cognitive deficits, learning disabilities and other neurological related problems. They should be referred for diagnosis and treatment.
Pharmacologic treatment should be initiated for children who have both hypertension and diabetes, symptomatic hypertension, hypertension > 95% tile, when end-organ damage is present. Obesity is a risk factor, but is not a sole indicator of treatment.
Two strategies should be tried initially. First, avoidance of overfeeding is recommended. Hence, small, frequent feedings. Second, milk thickening agents appear to improve symptoms in infants who experience gastroesophageal reflux (GER). Thickened feedings significantly decrease frequency of reflux in most infants. Also, caloric content is increased and this may be helpful for patients who are underweight because of persistent GER. Generally, when medications are used, proton pump inhibitors are preferred over an H2 blocker like cimetidine. Changing formula generally does not help, however, a milk-free diet may help since 40% of infants with GER are sensitive to cow’s milk protein. Thus, soy would not help. Positioning seems to be ineffective in relieving symptoms in infants.
The underlying cause of encopresis, repetitive soiling of stool by a child who is 4 years of age or older who should be potty trained, is usually chronic constipation. The ultimate goal is to reverse the constipation and establish normal bowel habits by the child. Having the patient use daily laxatives reverses constipation. Once he is able to have one soft bowel movement daily and a routine has been established, the laxatives are slowly weaned off. Attention to dietary factors must be addressed so that the child’s diet will support a daily bowel movement.
In children less than 5 years old, the most common cause of pneumonia is a viral pathogen. Rarely are studies performed to identify viral pathogens, however one of the most common viral pathogens is respiratory syncytial virus (RSV). S. pneumoniae is a common cause of pneumonia in very young children, it is also implicated in elderly adults as a causative agent in pneumonia. In adolescents, Mycoplasma is the predominant pathogen.
There are several diagnoses in the differential. The assessment of this child should begin in the office. Asking the child to stand on the affected leg performs the Trendelenburg’s test. If there are weak adductor muscles in the affected hip, a pelvic tilt will be visible in the unaffected hip. This can be found in children with a slipped capital femoral epiphysis, Legg-Calve-Perthes disease, or developmental dysplasia of the hip. After assessment of the hip, knee, and gait in the office, a hip x-ray to include AP and lateral should be ordered. The advantage of a sedimentation rate or C-reactive protein is that it will be elevated in patients with the aforementioned hip problems. It will be elevated in septic arthritis and other inflammatory causes of hip pain.
Children with sickle cell anemia should receive all the routine childhood immunizations at the usual time for administration, including annual flu immunization. Sickle cell crises arise when children become ill. Unfortunately, children with SCA are more prone to sickle cell crises when illness occurs, so, decreasing the likelihood of illness by immunization decreases the likelihood of sickle cell crises.
Fifth disease, erythema infectiosum, is a common viral exanthem seen in children 5-15 years of age. This produces a maculopapular rash that blanches easily. This rash is not pruritic but may last for several weeks before it completely goes away. Children are allowed to attend school as long as they have been fever free for 24 hours. Discomforts of this illness (fever, body aches, etc.) may be treated with acetaminophen or ibuprofen. Adults who are exposed to children with Fifth Disease can complain of arthralgias and myalgias for several weeks.
Common developmental tasks for 3 year-old include: standing on one foot, riding a tricycle, saying his name, gender, and age, copying a circle, and recognizing some colors.
Several maneuvers may be attempted to elicit the dislocation. The physical exam techniques used to identify hip dislocation are Ortolani’s and Barlow’s maneuvers. Both attempt to dislocate or reduce the hip. There is a distinct “clunk” which can be felt by the examiner and sometimes heard as well. Each hip should be assessed individually and several times.
A mucopurulent eye discharge bilaterally in a one week-old infant sounds like genitourinary in origin. The mother may have Chlamydia. If the infant is delivered vaginally and the mother is infected with Chlamydia, symptoms will appear 1-2 weeks post-delivery in the infant. The discharge is mucopurulent and would not be confused with the discharge associated with a plugged tear duct. Other STDs like gonorrhea could produce symptoms 2-4 days post vaginal delivery.
The Tanner scale indicates the stages of sexual development of males and females. The development of sexual characteristics is described based on the Stage. An average 8 year-old would be expected to be pre-pubertal. This is characterized as a Tanner Stage 1. Pubertal changes can occur as early as 9-10 years in males or females. If changes occur prior to this, precocious puberty should be considered.
Tinea cruris, “jock itch” is common during warm months and in humid areas. It is a fungal infection that affects the scrotum and inner thighs, but never affects the penis and is never evidenced by scrotal swelling. He is probably at increased risk because he is working as a lifeguard and may wear damp or wet swim trunks during work. He should be treated with a topical antifungal cream, advised to dry off after swimming and put on dry swim trunks.
Successful reduction occurs when the child moves the affected arm at the elbow. Normal range of motion is established immediately if done correctly. X-rays are not needed. There is no visible deformity when subluxation occurs. The examiner’s clue is clinical history and position in which the child holds his arm. When the examiner performs the reduction, the examiner may feel a click over the radial head when the arm is hyperpronated.
Strabismus may be completely normal in the first few months of life. Persistent strabismus at any age likely indicates eye muscle weakness, cranial nerve abnormalities or a number of other pediatric eye diseases. The infant with a normal red reflex probably does not have retinoblastoma or congenital cataracts, but both of these conditions can result in strabismus. This infant should be referred to an ophthalmologist for evaluation if he has persistent strabismus.
This describes a patient with roseola or exanthem subitum. This is a common viral exanthem found in young children caused by the Human Herpes Virus 6B. It is characterized by high fever for 3 days followed by the abrupt cessation of fever and the appearance of a maculopapular rash. This usually resolves in a few days. The child may return to school or daycare when he has been fever free for 24 hours.
An erythematous TM can be caused by the conditions listed above. Coughing does not produce an erythematous TM. The tympanic membrane (TM) can take on numerous colors depending on the condition or status of the patient. Under normal conditions, the TM is usually described as pearly gray or pink. When there is fluid behind the TM, it may take on a white, gray, or blue appearance. When pus is present behind the TM, it can appear white or yellow.
Generally, infants and children need about 3-4 mg/kg/day of elemental iron in divided doses. Since iron is better absorbed in an acidic environment, orange juice is recommended. Iron is better absorbed on an empty stomach, so the preference is to take it between meals. However, oral ferrous sulfate is poorly tolerated by some patients and may be better tolerated with food. If this is the case, a rise in hemoglobin will be at a decreased rate.
A sprained ankle is a common orthopedic injury in athletes. Resumption of regular activities can take place when he is able to walk pain-free. His ankle does not necessarily need taping prior to competition but it may need support with an orthotic device. The edema may take weeks to completely resolve. In fact, edema after resumption of athletic activities is common.
Benzoyl peroxide can produce sensitivity to the sun and so adolescents should be informed of this. This product can be used twice daily. It can cause peeling of the skin, but this is not a frequent occurrence. Hypersensitivity can occur with any topical product and is not specific to benzoyl peroxide.
Maternal diabetes increases the risk of the above named diseases. Congenital infections like cytomegalovirus, herpesvirus, rubella, or coxsackie virus can increase the risk of many cardiac structural abnormalities. TORCH is an acronym used to describe 5 maternal infections that are deleterious to the fetus. The acronym TORCH stands for Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus (CMV), Herpes simplex virus (HSV).
Dyslipidemia assessment does not necessarily mean a lipid profile, though these are recommended between 18 and 21 years of age. Dyslipidemia assessment refers to assessing family history of dyslipidemia, premature cardiovascular disease, or diabetes, body mass index > 85% for age and sex, or history of other systemic diseases like Kawasaki Disease or treatment, or renal disease.
In this age group (> 5 years), the most common pathogen is an atypical one like Mycoplasma or Chlamydia, therefore a macrolide is the preferred agent. It is usually chosen first for its coverage of atypical pathogens. Doxycycline is not an appropriate choice because it is contraindicated in children younger than 8 years, however, it does provide coverage against the atypical pathogens. Amoxicillin provides no coverage of atypical pathogens and so it is a poor choice.
The child should be referred to pediatric cardiology. A grade 4 designation for a murmur indicates that a murmur is loud and has a thrill associated with it. The finding of a thrill is always an abnormal finding and requires referral. A thrill can be palpated with the examiner’s hand over the anterior chest in the area of the point of maximal impulse (PMI).
Palpable or visible pulsations are common if the infant is crying or is agitated. Normally, the anterior fontanel is slightly depressed, but a depressed fontanel is indicative of a dehydrated or malnourished infant. Pounding pulsations are indicative of increased intracranial pressure. A palpable nodule near the posterior fontanel is an abnormal finding possibly indicative of a calcium deposition or bony abnormality.
The primary imaging technique for assessing DHH in the first 3-4 months of life is ultrasound. The biggest limitation is the experience of the ultrasonographer. X-rays are of little benefit in the first few months of life because the femoral head is mostly cartilaginous and unossified. After 3-4 months of age, AP x-rays of the hip are more valuable. The frog leg view of the pelvis provides the lateral view of the femoral heads. During treatment or to confirm reduction post-operatively, a CT may be valuable.
This is a femoral hernia. Testicular torsion is a medical emergency. The testicle is swollen, not the upper thigh. Varicocele and hydrocele are both confined to the scrotum. Hydrocele is evidenced by scrotal swelling, is painless, and is easily transilluminated. The varicocele is confined to the scrotum too, but presents most commonly in the adolescent age group with a large, soft scrotal mass that decompresses when the child lies down.
The child may have had a febrile seizure at the daycare related to a sudden elevation of body temperature. The sudden rise (or even fall) of body temperature can precipitate a seizure in young children. The most common diagnosis associated with febrile seizures is otitis media. The mother should be advised about behavior to watch for that could indicate the child is having a seizure. If this behavior occurs again, the child should be brought for neurological evaluation. Information should be provided to the caregiver regarding management of elevated body temperature in the child.
Infants who burp frequently probably are swallowing too much air with feeding. This is likely not related to congenital heart disease. Some red flags associated with feeding that should prompt the examiner to assess for congenital heart disease include feedings that are interrupted by choking, gagging, or vomiting. Some infants have rapid breathing with feeding or a persistent cough or wheeze. These should be assessed and CHD should be considered.
Allergy to duck meat, duck feathers is not a contraindication to any allergy even if the child has had an allergic reaction to chicken eggs. He should receive all needed immunizations today.
This constellation of symptoms is typical of a viral infection. Group A Streptococcus is usually not accompanied by coryza. H. parainfluenzae is not a common cause of pharyngitis. Mycoplasma usually is associated with lower respiratory tract infections.
ADD and ADD with hyperactivity are two separate diagnoses. This disorder is more common in boys (5:1) and symptoms must be present by age 7 for at least 6 months before diagnosis can be made. DSM V should be used to diagnose children. Parents and/or teachers should establish specific elements. Examples include fidgeting, difficulty remaining in seat, excessive talking, impatient when asked to wait their turn, blurting out answers before time, and interrupting conversation. These must be established in more than one environment.
Common developmental tasks for an 18 month old include: walking backwards, throwing a ball, saying 15-20 words, pointing to multiple body parts, pointing and naming objects in a book, and stacking 3-4 blocks.
Common developmental tasks for a 2 year-old include: stacking 5 blocks, following 2 step commands, using 2 word phrases, kicking a ball, saying at least 20 words, and walking up and down stairs one step at a time.
Two clinical clues should make the examiner suspect a foreign body. First, the patient has continued drainage despite treatment. Second, the drainage is unilateral. Unilateral drainage from a nostril should prompt the examiner to visualize the turbinates. In this case, a foreign body could probably be visualized.
In full-term infants, the bilirubin level peaks at 3-4 days. In premature infants, the level peaks at 5-7 days. This is diagnosed when the bilirubin level exceeds 5 mg/dL. It occurs in more than 60% of full-term infants.
Growth spurt in girls takes place earlier than boys. In girls of North American origin, the growth spurt occurs between 10 – 12.5 years. Completion of the growth spurt occurs later in boys but not usually before 16 years of age. In girls, completion of the growth spurt can occur as early as 14.5 years.
Egg allergy is no longer considered a contraindication for the MMR vaccine. The measles vaccine is grown in a chick embryo medium but several large studies have demonstrated efficacy and safety. The immunization is attenuated and considered safe if given at 12 months of age. It is repeated once at age 4-6 years.
Middle ear effusion refers to the presence of fluid in the middle ear. This is present in both otitis media with effusion and acute otitis media. Since the eardrum appears normal and the fluid does not appear infected, there is no reason to suspect otitis media, acute or with effusion. Another name for otitis media with effusion is serous otitis media. Other terms for this are secretory or nonsuppurative otitis media.
This describes ringworm. It is a fungal infection that is common in children. A typical precipitant is a new animal like a cat. Since it appears on the inner forearm, it is likely the child got this from holding the cat. It should be treated with a topical anti-fungal agent.
This patient experienced a Type I allergic reaction to penicillin. This is characterized by hives, wheezing, or anaphylaxis. It is NEVER considered safe to prescribe a cephalosporin. Macrolides may be prescribed to patients with a true Type 1 reaction to penicillin. Since amoxicillin is a penicillin, it should not be prescribed.
Metatarsus adductus (MA) is the most common congenital foot deformity. It is not related to clubfoot. In MA, the forefoot deviates medially, the hindfoot remains in a neutral position. This is a common cause of in-toeing gait and usually spontaneously corrects. This can be diagnosed on clinical presentation. An x-ray is not necessary. Casting is usually reserved for severe MA characterized by a rigid forefoot.
Aspirin is always avoided in the case of viral infections in children and adolescents. The incidence of Reye syndrome is increased if aspirin is given. This is especially true with varicella and influenza infections. The typical constellation of symptoms occurs during a bout of chickenpox and includes nausea, vomiting, headache, excitability, delirium, and combativeness with progression to coma. Since aspirin use has declined sharply, Reye syndrome has too.
The NP must visualize the area during exam so that an appropriate diagnosis can be made. Since the child is 9 years old, she should be given the opportunity to remove her blouse before allowing another adult to do this. Allowing the child to do this will put “control” in her hands.
Coarctation is frequently missed on initial assessment. This disorder is characterized by elevated blood pressures in the upper extremities and diminished blood pressures in the lower extremities. It can be assessed by measuring and comparing blood pressures in the upper and lower extremities.
The cover/uncover test is used to assess strabismus, a common cause of disconjugate gaze. Strabismus represents a nonparallelism of the visual axis of the eyes. This results in the inability of both eyes to focus on the same object at the same time. At 6 months of age, a disconjugate gaze and tilting of the child’s head is a red flag. This child needs referral to ophthalmology. While an ocular tumor could be present, this is unlikely and not the action that should be taken today.
A sudden rise or fall in body temperature lowers the seizure threshold in children as well as adults. Therefore, gradually decreasing body temperature with antipyretics, consuming cool fluids, or removal of clothes is prudent when temperatures are > 101F. Fever is the most common precipitant of a febrile seizure. The most common diagnosis associated with febrile seizures is otitis media; pneumonia does not specifically increase the risk. Returning to daycare before being fever free for 24 hours increases the risk of transmission of most contagious illnesses, but, not seizure.
The tympanic membrane normally becomes pink and can rarely become red when a child is screaming or crying. This is probably due to flushing and hyperemia of the face that occurs with crying. A distorted or erythematous tympanic membrane with decreased mobility is suggestive of otitis media.
Infants younger than 6 months and children older than 3 years typically do not exhibit stranger anxiety when the examiner enters the room. There is no known difference between stranger anxiety in male and female children. The most specific time for stranger anxiety to develop is about 9 months.
Blood pressure is not routinely measured in children younger than 3 years of age unless an underlying abnormality such as coarctation of the aorta, tumor, nephrotic syndrome, renal artery stenosis, etc. is suspected or diagnosed. Routine blood pressure measurement usually begins at 3 years of age if the child is cooperative. Usually the first indication that a patient has renal artery stenosis is an elevated blood pressure. Changes in functioning of the kidney occur after damage to the kidney occurs.
Initial vision screening should take place at 3 years of age. If the child is not cooperative, screening should be attempted 6 months later. If the child is still not cooperative at 3.5 years, it should be attempted at 4 years. Generally, children are cooperative at 4 years of age. The usual vision of a 3 year-old is 20/50.
If the infant has thrush, he should be treated with an oral anti-fungal suspension like nystatin. This is given 4 times daily after feedings. Since the mouth of the infant is in contact with the mother’s nipples during breastfeeding, and they sound infected too, the mother and infant should be treated simultaneously. Care should be given so that the mother gently washes her nipples and dries them before breastfeeding. This will minimize or eliminate ingestion of the topical anti-fungal in the infant.
The minimum length of time between Hepatitis B, DTaP, IPV, and MMR is one month. Therefore, he can receive all of these today. He should not receive another varicella today. The minimum length of time between immunizations is 3 months if he is less than 13 years of age.
At 9 months of age, the baby will continue to take formula through a bottle while supplementing with solid foods. Parents should be encouraged to give the baby 3 meals and at least 2 snacks daily. Encourage the use of a cup, with plans to wean from the bottle by 1 year of age. Syrup of Ipecac is no longer recommended, however, the number to poison control should be readily available. The average 9 month old has a vocabulary of 1-3 words. Typically babies begin to experience stranger anxiety at about 6 months, peaks at 9 months and ends at 12 months. It may reoccur around the age of 2.
Normal heart rate varies with age. Generally, as the heart becomes more efficient, the rate begins to decrease. This occurs with age. Four and six year-old children can be expected to have normal heart rates between 60 and 140 beats per minute. By age 10 years, the usual heart rate more closely approximates that of an adult, 60-100 beats per minute.
A child’s vision should be screened beginning at age 3 years if he is cooperative. The vision of a 3 year-old should be about 20/50. A 4 year-old’s vision is usually 20/40. By 5 years of age, vision is usually 20/30. By 6 years of age, a child’s vision should be approximately normal, 20/20.
A patient with scarlet fever (scarlatina) has a common childhood disease that is characterized by sore throat, fever, and a scarlet “sandpaper” rash. The causative organism is Group A beta hemolytic Streptococcus pyogenes. The patient’s rapid strept test will likely be positive. If the rapid Strept test is negative, the throat swab should be positive. Diarrhea with abdominal cramps is not specific to scarlet fever. Petechiae represent an extravasation of blood under the skin and are not present with scarlet fever unless some other disease process is present. Petechiae should be considered to be a very serious finding.
There are several ways to determine how elevated the bilirubin level is. One measure is to use the Bhutani nomogram. It predicts bilirubin levels based on post-natal age. A level of 16 mg/dL is considered high intermediate. Since the bilirubin probably will rise a little more, phototherapy is probably appropriate.
A serum pregnancy test is highly sensitive even early in pregnancy and is prudent today. If the serum pregnancy test is negative, it is unlikely that this patient is pregnant. This patient should be counseled regarding issues of safe sex and STDs. Because she presents for an exam and requests a pregnancy test, a parent or guardian is not needed for consent because parental consent is not required for a reproductive issue in a sexually active adolescent.
Babies will lose about 10% of their birth weight in the first 3-4 days of life. This baby has lost about 8 ounces; this is about 10% of his birth weight. This is an appropriate weight loss in this time. He should rapidly gain this weight back. When children begin losing weight and growth slows, one consideration should be given to congenital cardiac anomalies. There is no need for the mother to return in one week to re-weigh this infant. The infant should be asked to return for his 2 month check.
Asking a child with a complaint of hip pain to stand on the affected side is how the Trendelenburg test is assessed. A positive Trendelenburg test occurs when standing on the affected leg causes a pelvic tilt, such that the unaffected hip is lower. This can be assessed and observed in children with slipped capital femoral epiphysis, Legg-Calve-Perthes disease, or developmental dysplasia of the hip. Nursemaid’s elbow is a common ligamentous injury in young children. The radial head becomes subluxed. Displacement is usually easy to reduce.
The head of infants and children up to 18 months of age is commonly 1-2 cm larger than chest circumference. The chest circumference is measured at the nipple line. This is not routinely measured at well-child visits, but is assessed if there is concern about the circumference of either head or chest. An exception to this observation can occur in premature infants where the head grows very rapidly.
About 40% of children have effusion at 4 weeks post-acute otitis media. This should be monitored and not treated with another antibiotic. Effusion is a stage in the resolution of otitis media. Pneumatic otoscopy will identify the presence of fluid or pus behind the TM, but will not help in diagnosis or treatment once an effusion has been established. A tympanogram will establish that her hearing is diminished, a fact which should be assumed since there is fluid in the middle ear.
In this age group, specifically 4 months to 4 years, the most common pathogen is Streptococcus pneumoniae, therefore, amoxicillin is the preferred agent. It is usually chosen first for its efficacy, cost, and tolerability. The higher dose (80-100 mg/kg/d) is chosen because of the prevalence of resistant Streptococcus pneumoniae. Azithromycin would be chosen if an atypical pathogen was suspected. Doxycycline is not an appropriate choice because it has poor Strept coverage and it is contraindicated in children younger than 8 years.
There are many different presentations of psoriasis. Plaque psoriasis, which is described in this question, is usually found in a symmetrical distribution on the scalp, elbows, knees, and/or back. The size of the lesions ranges from 1-10 cm in diameter. Usually the plaques are asymptomatic, but may be mildly pruritic. Scaly lesions found on the scalp are not specific to psoriasis and could be seborrheic dermatitis. A scaly border around the plaque could describe the lesions associated with pityriasis rosea.
Recurrent abdominal pain can be diagnosed after three episodes of abdominal pain that severely affects the child’s usual activities and occurs over at least a three month period. No acute cause can be identified. Fewer than one in 10 children with recurrent abdominal pain attends school regularly. The goal in treating these children is a return to normal function and activities, not necessarily relief of pain. Caregivers must be coached to avoid reinforcement of pain behaviors with the child.
This child’s platelet count is below normal. The term used to describe this is thrombocytopenia. ITP is the most common type found in children between the ages of 2-4 years. Nosebleeds and bleeding gums, especially with brushing of teeth, are common. Generally, children are monitored closely for decreasing platelet counts and bleeding after ITP is identified, but this usually resolves in several weeks without treatment. The underlying cause is unknown, hence the name idiopathic. A common historical finding is an upper respiratory infection within the previous 4 weeks of the onset of ITP.
Streptococcal infections can present as a sandpaper textured rash that initially is felt on the trunk. Rubeola, measles, produces a blanching erythematous “brick-red” maculopapular rash that begins on the back of the neck and spreads around the trunk and then extremities. Varicella infection produces the classic crops of eruptions on the trunk that spread to the face. The rash is maculopapular initially and then crusts. Roseola produces a generalized maculopapular rash preceded by 3 days of high fever.
Scoliosis is diagnosed when the degree of curvature is 10? or more. It is more common in girls because they have more rapid vertical growth than boys. There is not a strong familial component to this disease. Rather, it is idiopathic. It is assessed using the Adams Forward Bend test. There can be unequal scapula prominences and heights, waist angles, and chest asymmetry.
The patient has an acute swelling of the groin. Since the etiology could include several scrotal problems (inguinal hernia, hydrocele, or varicocele), an ultrasound will yield quick reliable information with a diagnostic accuracy of 93% for acute groin problems. The definitive treatment for inguinal hernia is surgical repair.
Osgood-Schlatter disease occurs during a growth spurt when the knee is subjected to activities that place repeated stress at the superior tibia. The quadriceps, especially after certain activities (running, jumping, and bending of the lower leg), exert stress on the patellar tendon, which pulls on the tibial tuberosity. This produces swelling at the tibial tuberosity and pain, especially with running, jumping, and bending of the knee. Vigorous exercise during non-growth periods will not produce Osgood-Schlatter disease.
Chickenpox is highly contagious and can be spread via respiratory secretions from an infected individual or by direct contact from the vesicle fluid from lesions on the skin or mucus membranes. The usual incubation period is about 2 weeks but can be as long as 21 days or as short as 10 days. The greatest period of infectivity is 48 hours prior to the onset of the rash and until all the skin lesions have crusted over.
There are three categories of symptoms: hyperactivity, inattention, and impulsivity. The diagnostic criteria have been defined by the American Psychiatric Association and can be found in the DSM V.
Varicella and MMR should be avoided until allergy testing can take place. However, according to CDC, this patient should be skin tested prior to administering either of these vaccines to establish sensitivity to gelatin. IF the skin tests are negative, the vaccine can be given as with non-allergic children. Other than MMR and varicella, there are no contraindications to any other US immunizations.
A 6 year-old with CAP should show improvement in symptoms in 24-48 hours if he is on appropriate antibiotic therapy. Azithromycin treats atypical pathogens like Mycoplasma and Chlamydia, but, has poor Strept coverage. The most likely pathogen in this age group that causes pneumonia is an atypical pathogen, but, at this point the most common typical pathogen, Strept pneumo, must be considered. The best choice is to consider Strept as the pathogen and treat with a penicillin. Specifically, this patient should receive high dose amoxicillin because of the increased incidence of resistant Strept pneumo.
Risk factors for SIDS are maternal age < 19 years, SIDS in a sibling, not a second degree relative. Male gender is a risk factor since more males have SIDS than females. Low birth weight babies are at increased risk of SIDS.
Bone pain is common in children, especially adolescents. However, a six year-old with complaints of mid-bone pain should be evaluated for ALL. Osgood-Schlatter produces pain in the knees. Growing pain usually occurs at nighttime. There is no information from history to suggest psychogenic pain, but ALL must always be considered since it is the most common malignancy in children. The child should be assessed for lymphadenopathy since this accompanies bone pain in ALL at least 50% of the time.
The heptavalent pneumococcal conjugate vaccine (PCV7), Prevnar?, protects children from the seven most common strains of Streptococcus pneumoniae (S. pneumo). It has reduced the incidence of ear infections caused by S. pneumo and has reduced the incidence of recurrent ear infections and tube placement by 10-20%. The pathogenesis of acute otitis media has shifted to more cases of H. influenzae, but, this organism is less likely to become resistant, as Strept pneumo has.
This situation describes a hydrocele. It is very common in young males and usually resolves by a year of age. If it has not resolved by 12 months of age, the patient should be referred to urology. A cystic mass in the scrotum with a description of changing in size of the scrotum supports the finding of a communicating hydrocele. A scrotal ultrasound is not indicated at this time.
This child has a vaginitis. There are many diagnoses in the differential including pinworms, yeast, contact irritants from soap or bubble bath, etc. Since the diagnosis is not clear, some evaluation must occur in order to determine the diagnosis so proper treatment can be initiated. Since the description of the problem does not indicate what the diagnosis is, it is inappropriate to treat with a cortisone cream or topical antifungal.
Bronchiolitis is a viral infection and antibiotics would be inappropriate for management. Since fever commonly accompanies bronchiolitis, antipyretics such as acetaminophen and ibuprofen are commonly used. Bronchiolitis is characterized by wheezing, and so bronchodilators, especially nebulized, are commonly employed to decrease respiratory effort. Oral steroids are controversial in bronchiolitis but are commonly used in infants and children when there is significant edema in the small airways.
A patient with otitis externa has swimmer’s ear; an infection of the external canal. The classic complaint is tragal pain or even pinnae pain. If there is such significant edema in the external canal, hearing may be impaired, but, the most common complaint is tragal pain. Systemic complaints do not accompany swimmer’s ear unless a second diagnosis is present simultaneously. Fever and upper respiratory infection are not likely.
There are two important differential diagnoses with the development of scrotal pain: testicular torsion and epididymitis. Because of the history of this occurring following groin trauma, and the fact that he is an adolescent, testicular torsion must be excluded. If testicular torsion is the cause of his pain, getting this patient into the ER/hospital so that torsion can be reversed must be paramount to the treatment decision. Obtaining an ultrasound will delay treatment and that decision should be deferred to the urologist. Reversal of the ischemia should take place within 4-6 hours of the onset of pain in order to protect the viability of the testicle.
Cryptorchidism is the condition where one or both testicles have not descended into the scrotum by birth. This can be due to a short spermatic artery or poor blood supply. During normal prenatal development, the testicles develop in the abdominal cavity and descend through the groin tissue forming a scrotal sac. The incidence in premature birth is about 30% compared to full-term male infants where the rate is about 3%.
A 6 month old with acute otitis media and temperature of 103F is considered moderately ill. Persons with moderate or severe illnesses, with or without fever, can be vaccinated as soon as they are recovering and not considered acutely ill. Antibiotics would not be considered a contraindication for any routine immunizations today. Pregnancy in the mother would not contraindicate any immunizations today. Live vaccines would be contraindicated if a family member was on chemotherapy, however, a 6 month old will not be receiving any live viruses.
Examination of the mouth may begin at birth, but oral health screening should begin at 6 months of age. Part of the screening should be for the need for fluoride supplementation. Oral health risk assessment should take place at 6 months, 9 months, and referral to a dental home should take place by one year of age. Oral health risk assessment should continue periodically at health screening visits at 18, 24, and every 6 months until a dental home is established.
A male in Tanner Stage II will have an increase in testicular volume from 1.5 ml or less, to up to 6 ml. The skin on the scrotum will begin to thin, redden, and enlarge. The penile length will remain the same.
The nurse practitioner is responsible for treating the sinus infection but has also become aware of a potentially harmful situation involving the elevated blood pressure and oral contraceptive use. The safest and most professional action is to call the dermatologist to discuss your concerns regarding the elevated BP and concomitant oral contraceptive use since this potentially increases the risk of stroke in this adolescent. Care and professional courtesy should be exercised when discontinuing a medication that another provider has initiated. Professional courtesy is extended to the prescriber by calling them prior to discontinuing a medication they have ordered.
A one month old infant would be expected to exhibit the Moro, stepping, rooting, and Babinski reflexes. The tonic neck, or “fencing” reflex isn’t exhibited until about 2-3 months of age. This is assessed by lying the baby on his back and turning his head to one side. If the reflex is present, he should extend his arm on the side that his head is turned. The opposite arm assumes a flexed position. This pose mimics a fencer and thus, the name.
Infants born vaginally to mothers who have chlamydia have a 60-70% risk of acquiring C. trachomatis. Newborns may present with pneumonia and/or conjunctivitis. The most common clinical feature is conjunctivitis that occurs 5 to 14 days after delivery. It is characterized by swelling of the lids and a watery discharge that becomes mucopurulent. The conjunctivae are erythematous. This must be treated orally because topical treatment is not effective. The drug of choice in infants is oral erythromycin 50 mg/kg/day in divided doses for 14 days whether treating pneumonia or conjunctivitis.
This is not a clinical presentation of trichomonas because this produces a discharge. Syphilis produces a painless lesion but it presents as an ulceration with a hard edge and clean, yellow base. Herpes produces lesions, but these are painful and produce burning. HPV, human papilloma virus, produces warty growths as described above.
A 4 year-old should have the dexterity to cut and paste. Therefore, this is the most appropriate age. A 5 or 6 year-old may also use these items, but these would be appropriate as early as 4 years. Pointed tips represent hazards especially in a classroom with multiple children moving simultaneously.
The diagnosis of pinworms, Enterobiasis, is made by using a piece of scotch tape on a tongue depressor. It is touched against the child’s rectum. The greatest yield of eggs will occur during the nighttime or early AM. Eggs will be found here if they are present. Worms and eggs are rarely found in stool specimens, so this is not a good plan. When the scotch tape is examined under a low power microscope, the eggs will be easily visualized since they are large and bean shaped. The finding of an adult worm would confirm the diagnosis. These are large enough to be seen with the naked eye.
Koplik’s spots are found in the oral cavity, especially on the buccal mucosa opposite the first and second molars. The spots are white and granular and are circled by an erythematous ring. The spots are pathognomonic for measles. There is an exanthem associated with measles. It typically is described as cranial to caudal in progression. The lesions become confluent and last for approximately 4 days before fading begins.
MMR is an attenuated virus. Varicella is a live virus. They should be given on the same day or, at least one month must separate the two. The reason for this is that higher titers are achieved if they are given together as opposed to being given separately.
Inguinal hernias are usually asymptomatic and absent on exam but can sometimes be elicited by increasing intraabdominal pressure such as occurs with straining or crying. The “silk sign” is infrequently appreciated but represents a silky thickening of the cord. If it is able to be palpated, it is done by placing a single finger next to the inguinal canal at the level of the pubic tubercle and gently moving the finger from side to side. Children with an incarcerated mass are often irritable but not constipated.
This describes colic. Colic is a symptom complex characterized by episodes of inconsolable crying accompanied by apparent abdominal pain. It typically occurs between 1-3 months of age and usually in a very predictable pattern, typically in the evening after feeding. Many different approaches are tried, but medication like ranitidine is not indicated, changing formula is not indicated either. Parents need education regarding colic, comfort measures like rhythmic rocking or frequent burping, much reassurance, and encouragement.
Amoxicillin, doxycycline, and cefuroxime have all been shown to have equivalent efficacy for treatment of Lyme disease. However, because this patient is only 6 years old, he should not be given doxycycline as a first line treatment unless the other regimens are contraindicated. Macrolides, like azithromycin should not be used first line because they are poorly effective at eradicating infection. They may be used in patients who are intolerant of penicillins and cephalosporins and who cannot take doxycycline. First generation cephalosporins like cephalexin are not effective.
Otitis media with effusion (OME) frequently precedes or follows an episode of acute otitis media. This condition should not be treated with an antibiotic since the middle ear fluid is not infected. However, the fluid acts as a medium for bacterial growth.
This child’s hemoglobin should have increased if he is receiving the iron as prescribed, and there is no other disease process occurring. If the child’s hemoglobin is not increasing, the instructions for administering the iron should be reviewed with the caregiver and the dosage should be re-calculated. If the hemoglobin does not improve despite this, further assessment is needed.
This child will be placed on CDC’s catch-up schedule (a copy can be downloaded from CDC’s website). Because of his age, he does not need a Hib immunization. He does need all of the immunizations listed in choice C.
The recommendations from the American Academy of Pediatrics are 5-7 days of an antibiotic for children 6 years and older who have mild to moderate acute otitis media (AOM). Children less than 2 years of age should be treated for 10 days. Children 2 years and older may be treated for 5-7 days for AOM if they do not have a history of recurrent AOM.
Sickle cell anemia is initially suspected on visual exam of the red cells. They have a sickled-shape, hence the name sickle cell anemia. These cells can be identified as early as 3 months of age. Once a positive screen is identified, it is repeated using either hemoglobin electrophoresis or DNA analysis.
The visualization of yeast, hyphae, pseudohypha in saliva usually indicates Candida species. The diagnosis of thrush is usually made on clinical presentation and there is no need for KOH. Spores are a form assumed by some bacteria and fungi that are extremely resistant to heat and consequently are very difficult to kill.