Many patients have exquisite tenderness of the gastrocnemius muscle. It is important not to delay treatment. RMSF is one of the few indications these days to use chloramphenicol. It is seldom used anymore due to potential for hepatotoxicity and associated complication of gray baby syndrome. Typical Scenario A year-old boy steps on a dirty nail that punctures his foot through his sneaker. Think: Wound likely to become infected with Pseudomonas.
Suturing indicated if no obvious signs of infection. Esophageal atresia. Radiograph demonstrating air in the upper esophagus arrow and GI tract, consistent with esophageal atresia. Esophageal foreign body. A coin in the esophagus will be seen flat or en face on an AP radiograph, and on its edge on a lateral view. Photo courtesy of Dr.
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Julia Rosekrans. In the last 2 weeks, the nurses have noted that he is regurgitating several times an hour. He makes chewing movements preceding these episodes of regurgitation. Think: Rumination. The most common cause of esophagitis is Candida. Physical exam shows a hungry infant with prominent peristaltic waves in the epigastrium. Think: Hypertrophic pyloric stenosis.
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Abdominal x-ray on the left demonstrates a dilated air-filled stomach with normal caliber bowel, consistent with gastric outlet obstruction. Barium meal figure on the right confirms diagnosis of pyloric stenosis. Note how there is a paucity of contrast traveling through the duodenum.
Photo courtesy of Drs. Julia Rosekrans and James E. Duodenal atresia. Note no distal gas is present. The proximal portion is usually drawn into the distal portion by peristalsis. Intussusception and link with rotavirus vaccine led to withdrawal of vaccine from the market.
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Note the markedly dilated stomach above the normal level of the left hemidiaphragm, in the thoracic cavity. Also present is a large left-sided diaphragmatic hernia.
Note the paucity of bowel gas in film A. Air enema partially reduces it in film B and then completely reduced it in film C. Abdominal x-ray following barium enema in a 2-month-old boy, consistent with intussusception. Note paucity of gas in right upper quadrant and near obscuring of liver tip. Uptake can be enhanced with cimetidine, glucagons, or gastrin. Luminal obstruction, venous congestion progresses to mucosal ischemia, necrosis, and ulceration. Bacterial invasion with inflammatory infiltrate through all layers. Necrosis of wall results in perforation and contamination.
Abdominal CT of a year-old girl demonstrating enlargement of the appendix, some periappendiceal fluid, and an appendicolith arrow , consistent with acute appendicitis. Laparoscopic removal associated with shortened hospital stay nonperforated appendicitis. Various laxatives and enemas have been tried in the past. Prior to toilet training, the girl had one bowel movement a day. Physical exam is normal except for the presence of stool in the sigmoid colon and hard stool on rectal examination. After removing the impaction, the next appropriate step in management would be to administer mineral oil or other stool softener.
Think: Anal fissure. The pain is unrelated to meals, and there is no diarrhea or constipation. Appropriate initial management would include all of the following: rectal exam; stool exam for ova, cysts, and parasites; complete blood count CBC and erythrocyte sedimentation rate ESR ; review of family emotional stress, except referral to an eating disorder clinic. Technically limited to lower GI tract. The stools are blood-streaked and contain mucus.
Sixty minutes earlier, the patient had a brief generalized seizure. Physical and neurologic exams are normal. Think: Shigella sonnei. Associated findings include cramps, emesis, malaise, and fever. May see systemic manifestations, GI tract involvement, or extraintestinal infections. Inflammatory diarrhea—fever, severe abdominal pain, tenesmus.
Noninflammatory diarrhea—emesis, fever usually absent, crampy abdominal pain, watery diarrhea. High osmolality may exacerbate diarrhea. Antimicrobial treatment for bacterial enteropathogens.
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Diarrhea is a characteristic finding in children poisoned with bacterial toxin of Escherichia coli, Salmonella, Staphylococcus aureus, and Vibrio parahemolyticus, but not Clostridium botulinum. Can diagnose with transparent adhesive tape to area worms stick. Common intestinal worms. Adapted, with permission, from Stead L. BRS Emergency Medicine. In inguinal hernia, processus vaginalis herniates through abdominal wall with hydrocele into canal. Inguinal hernia slippage of bowel through inguinal ring vs.
Antibiotics only in at-risk children e. Think: Peutz—Jeghers syndrome. Think: Gluteninduced enteropathy. Indirect hyperbilirubinemia, reticulosis, and red cell destruction suggest hemolysis. Direct hyperbilirubinemia may indicate hepatitis, cholestasis, inborn errors of metabolism, cystic fibrosis or sepsis. HAV causes most cases of hepatitis in children. May persist for more than 6 months acute infection.
IgG is detectable at this point. Typical Scenario A year-old boy is diagnosed with acute hepatitis A.
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How would you treat the parents and siblings who are doing fine? Think: IV immunoglobulin. They can be seen with the naked eye in patients with blue eyes. In patients with dark eyes, a slit lamp is often needed to identify them. Avoid spillage during surgery for Echinococcus— a major complication. Nasal flaring. Use of accessory muscles for breathing e.
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Restlessness, agitation. Pallor, cyanosis. Wheezing may or may not be present.
See Table for normal respiratory rates by age. Think: Rhinovirus. Think: Adenovirus. Normal respiratory rates in children. Influenza is an orthomyxovirus.