You see a 2-month-old infant in the emergency department for vomiting. The mother says that the baby has been spitting up more over the past few days and has become more irritable. She denies any fever, diarrhea, or change in formula. The mother tells you that there is a family history of "heartburn" and that her other children have all spit up. The infant has some emesis in the emergency department that seems to be formula mixed with some bile. The infant is intermittently irritable and sleepy.Which of the following would be the most appropriate initial test?
Answer(s): D
Bilious emesis in an infant is malrotation until proven otherwise. Malrotation can lead to a midgut volvulus. The volvulus can result in bowel ischemia and necrosis. This makes bilious emesis in a newborn a concerning finding. Pyloric stenosis would cause nonbilious emesis. Imperforate anus would present with the failure of stool passage. Diaphragmatic hernia will present with poor feeding, drooling, and respiratory embarrassment The best radiographic test in the diagnosis of malrotation is an UGI contrast study with small bowel follow through. This will identify the duodenum and its location relative to the ligament of Treitz. The characteristic finding in a midgut volvulus is the "corkscrew" sign, which is seen as contrast media traverses the kinked intestine. An abdominal CT may show malrotation but is less specific for it. Barium enema and radionuclide scans have no role in the diagnosis of malrotation
An 8-year-old male presents to your office complaining of a 1-week history of painful knee and elbow joints. On examination, you find a painful, hot, and swollen knee. He also has multiple erythematous macules with pale centers on his trunk and extremities. The laboratory work you order reveals elevated antistreptococcal antibodies.What is the most likely diagnosis?
Answer(s): C
ARF is clinically diagnosed by using the Jones criteria. The Jones criteria are separated into major and minor findings. The major criteria are arthritis (not simply arthralgia), carditis, Sydenham chorea, erythema marginatum, and subcutaneous nodules. The minor criteria include the presence of a fever, arthralgias, documentation of a GAS infection (either currently or in the past), or laboratory evidence of inflammation (increased ESR). Two major criteria, or one major and two minors, are required for the diagnosis of ARF. The only exception to this rule is that the presence of Sydenham chorea alone will make the diagnosis. While the documentation of a prior, or current, GAS infection is compelling, it is not a requirement for the diagnosis of ARF. Children with rheumatic fever are not considered contagious.
An 8-year-old male presents to your office complaining of a 1-week history of painful knee and elbow joints. On examination, you find a painful, hot, and swollen knee. He also has multiple erythematous macules with pale centers on his trunk and extremities. The laboratory work you order reveals elevated antistreptococcal antibodies.Which of the following information is required to make this diagnosis?
On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and ankles.What is the most likely diagnosis?
Answer(s): B
Acute inflammatory demyelinating polyneuropathy, commonly called Guillain-Barré syndrome, is an ascending paralysis with a hallmark of absent reflexes. There may also be some nominal sensory deficits as well, but they are not as striking as the paresis. Methylphenidate toxicity usually results in seizures and tachycardia. In children with malingering, reflexes are usually present, as they are not under cognitive control. Reflexes are also present in children with polymyositis. Children with polymyositis will usually have fever and muscle pain with weakness, as well. With the use of the polio vaccines (OPV or IPV), poliomyelitis is no longer present in wild type in the United States. Guillain- Barré is usually a self-limited disease.The most common complication is respiratory failure. The paresis usually advances for 4872 hours and then will slowly recede. The use of corticosteroids is not recommended. Plasmaphoresis is used in the following situations: progressive paresis, nonambulatory patients, or bulbar or respiratory involvement. As this child's disease has plateaued at the time of evaluation, plasmaphoresis would be of little benefit.
On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and anklesWhich of the following is the most appropriate initial management plan?
Answer(s): A
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