Case Study E4 Flashcards
(44 cards)
Child admitted with potential oligoarthritis what is the significance if Olga complains of blurred vision ‘floaters’ or photophobia
Big complication is iridocyclitis
10 yo admitted with tentative enthesitis what is the significance if he starts complaining of back pain
Potential complication of juvenile ankylosing spondylitis (JAS) where the back is hunched over/curved
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?
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
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?
Could be an infection related to the DMARD (it is a cancer med) this needs to be referred since it can cause major complications
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
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
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
Osgood-Schlatter Disease
Tx. Physical therapy, and rest, ice and compression (NOT elevation)
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
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
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
Legg-calve-perthes disease
Progression of disease 1. necrosis 2. fragmentation 3. re-ossification 4. remodeling
Tx: pinning and hip spica
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
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
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
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
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.
Enthesitis
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?
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
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?
First 6 hours, likely from anesthesia if over 24 hours likely an infection (meningitis) call immediately and expect antibiotics
Nursing assessments are important postop brain surgery in relation to these areas: Dressing, Positioning, Fluids/IO, Eye care
Dressing (watch for any clear drainage) Positioning (no elevated children, keep them flat and midline) Fluids (segars + mannitol for ICP) Eye care (artificial tears)
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?
Mets to the spinal cord
What are the similarities and significant differences between bacterial + viral meningitis assessment findings?
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)
How long are the two meningitis patients in isolation?
Viral - can be out of isolation as soon as its known it is viral
Bacterial - out of isolation after 24 hours on ABX
If a resident ordered a NS bolus for s child with meningitis what are your concerns?
Not an expected order, should definitely question, pt is on a fluid restriction (segars) we don’t want to raise the ICP
Likely outcomes for viral vs bacterial meningitis
Viral recover within a few weeks
Bacterial more likely to have complications (seizures, stroke, mental complications, DIC, organ failure, arthritis)
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)
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
What is the purpose (in pt with neuroblastoma) of the chest X-ray, skeletal survey, bone scan, bone marrow aspiration and liver function tests?
Checking for mets
Significance of following physical findings? Abdomen enlarged in RUQ - tender with palpation, Extremity pain, Pale bleeding gums petechiae, proptosis peri-orbital swelling with bruising
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
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?
The outcome is not as good, probably would have added radiation and upped the chemo
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.
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
