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Category: Pediatrics

A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

Templates do not just facilitate documentation but also can guide bedside observations. The person taking a history who uses OLD-CARTS might be reminded to ask a dimension of a symptom that otherwise would not have been elicited.   What does it mean to say a child is “well-appearing” or “ill-appearing?” I find the GCS (Glasgow Coma Scale) categories to be helpful:   Eyes – is the child attentive with the eyes Motor – is the child appropriately active/reactive Verbal –…

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BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?   In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The…

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TWIST AND SHOUT – DIAGNOSING OCCULT TODDLER’S FRACTURE

TWIST AND SHOUT – DIAGNOSING OCCULT TODDLER’S FRACTURE

A 2 year old presents with leg pain and a limp after slipping on a “slip and slide” water toy slide. X-rays are negative. The child will step when asked but will not walk on his own. Is this an occult fracture? This is a situation where the reference standard, radiography, has limitations in sensitivity. Studies show that using alternative tests reveal evidence of fracture, such as hematoma elevation on ultrasound (Lewis J Clin Ultrasound 2006) or MRI or delayed…

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RECOGNIZE APNEA RISK FOR BRONCHIOLITIS IN THE FIRST 2 MONTHS OF LIFE

RECOGNIZE APNEA RISK FOR BRONCHIOLITIS IN THE FIRST 2 MONTHS OF LIFE

A 5 week old presents with nasal congestion and difficulty breathing. RSV bronchiolitis is ultimately diagnosed. Can the patient go home? Not every infant with bronchiolitis can be admitted. But the ED provider must be aware that the dreaded complication of apnea tends to occur in patients who are under 2-3 months old. The studies on apnea from bronchiolitis are heterogeneous and the results are mixed. For example the incidence of apnea in newborns varies from <1% to 24% (Ralston…

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MANUAL REDUCTION OF SPERMATIC CORD (TESTICULAR) TORSION

MANUAL REDUCTION OF SPERMATIC CORD (TESTICULAR) TORSION

A patient presents with right-sided testicular pain and swelling for 1 hour, associated with nausea and vomiting. Physical examination shows tenderness and swelling in both the epididymis and testicle itself. The epididymis is anterior to the testicle, and palpation of the spermatic cord reveals a 1cm nodule about 2 cm above the testicle.   You call the urologist because the patient has spermatic cord torsion. While waiting you apply color Doppler ultrasound which confirms no flow. You try to untwist…

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SPERMATIC CORD TORSION (TESTICULAR TORSION): PALPATE THE CORD

SPERMATIC CORD TORSION (TESTICULAR TORSION): PALPATE THE CORD

Most people use the term “testicular torsion,” but throughout history it has also been called “spermatic cord torsion.” Many urologists prefer this term. One introduced it as “acute spermatic cord torsion, more commonly and not so exactly named testicular torsion (TT)…”(Drlik M. J Ped Urol 2013) The reason spermatic cord torsion is a better term is that it accurately identifies the pathologic organ. By neglecting to call it by its right name, we don’t necessarily realize that we can palpate…

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THE PEDIATRIC EXAMINATION PART 3: LOCALIZATION BY PROXY

THE PEDIATRIC EXAMINATION PART 3: LOCALIZATION BY PROXY

In the last 2 posts we discussed techniques for winning rapport and trust with children and for using distraction and play. We discussed a case of a 16 month old with scalp tenderness. In that case none of these techniques worked. So what do you do next? Parent’s Arms Most children between the ages of 1 and 3 will become more calm when examined in the arms of their mother or father. The child calms down, and clings to the…

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THE PEDIATRIC EXAMINATION PART 2: DISTRACTION AND PLAY

THE PEDIATRIC EXAMINATION PART 2: DISTRACTION AND PLAY

In the previous post we talked about using proper greetings and explanation to win rapport and trust. We talked about a 16 month old with scalp pain that could not be localized. Often efforts at rapport and trust do not work. What do you do next? For straightforward presentations there is nothing wrong with physical restraint and looking in the ears against resistance etc. William Carlos Williams has a short story “The Use of Force” where he makes this into…

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THE PEDIATRIC EXAMINATION PART 1: RESPECT AND EXPLANATION

THE PEDIATRIC EXAMINATION PART 1: RESPECT AND EXPLANATION

A 16 month old presented with pain in the scalp. The examiner was not able to localize it further because the child was uncooperative and crying. What now? To localize pain in a toddler, we need the child’s cooperation. There are three ways to achieve this. The first approach is to win rapport and trust. Introduction: I start with a proper introduction to the child on eye to eye level. If they are old enough to understand, I might say…

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GAIT ASSESSMENT: WALK THE WALK  

GAIT ASSESSMENT: WALK THE WALK  

A mother brings her 2 year old child in for a limp. The student believes the patient has ankle pain because she cried when she grabbed the ankle. After that she cried with everything. After calming the child down you watch her walk and it is abnormal but you wonder how to interpret this.   The last time I tried really hard to analyze gait and make recommendations, it was so complicated that no one could remember it. I now…

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