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Pediatric Migraine: Clinical Pearls in Diagnosis and TherapySteven, a 13-year-old boy, experienced his first headache at age 7 years. The frequency, intensity, and duration of his headaches have been increasing over the past 6 months. Steven now experiences 7 to 10 headaches each month that last up to 8 hours. The headaches are associated with mild nausea, light and sound sensitivity, dizziness, fatigue, occasional abdominal discomfort, and difficulty in concentrating. Last year, he had a vomiting episode because of a headache. The pain is usually more prominent in the forehead and does not favor either side of the head. The headaches usually begin in the morning before he leaves for school. As a result, Steven has missed nearly 25% of his school days this semester; his parents are considering home tutoring for "sick children who are unable to attend school."
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Cystic Hygroma in an Infant GirlUltrasonography showed a large multiseptated cystic mass in the posterior part of the left side of the neck. No obvious vascular flow evident within the mass (Figures 3 and 4).
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Shades of GrayMedicine is at least as much art as science. Often things are not clear-cut, but rather appear in shades of gray. We offer the following list of terminology for those who don't mind thinking in terms of black or white.
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Infant With Fat-Soluble Vitamin Deficiencies Caused by Cystic FibrosisA 3-month-old African American boy was referred for evaluation of poor weight gain and vomiting. The infant had been evaluated by his primary care physician 15 times within the past 6 weeks; he had no change in symptoms despite various treatments.
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The Uncontrollable Child: Family and Educational InterventionsIt is estimated that about 20% of children and adolescents meet criteria for a mental health disorder, and a high percentage of these youths are impaired by disruptive behavior problems.
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Two Missed Cases of Abuse: Lessons LearnedA 7-month-old male infant was brought to the emergency department (ED) by his biological mother, who reported noticing dried blood on the baby's penis and in his mouth. For several hours prior, he had been in the care of her boyfriend. On physical examination, there were severe ecchymoses and petechiae on the penile glans and shaft (Figure 1), ecchymoses on the right side of the soft palate, a laceration of the lingular frenulum, and a 2-cm bruise with dried blood over the right lip.
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Hematemesis Caused by Esophageal DuplicationA17-month-old girl was hospitalized 3 weeks earlier because of gagging and retching emesis that contained blood-streaked mucus. Her symptoms persisted and she was transferred to a tertiary care center for further workup.
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Photoclinic: Hirschsprung DiseaseA 30-hour-old boy--born to a 36-year-old gravida 3, para 3, at full term via a spontaneous vaginal delivery--was noted to a have a mildly distended abdomen while in the newborn nursery. He had been breast-feeding every 2 to 3 hours and initially was spitting up about a quarter of the volume he had consumed. During the last 3 or 4 feedings, he had been spitting up most of the milk. There was no bilious emesis. He had not passed meconium.
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That’s Not My Child: A Case of Capgras SyndromeMary, aged 40 years, was referred for psychiatric evaluation out of concern that a mental health diagnosis was interfering with her ability to appropriately and safely care for her child. The patient had stated on numerous occasions that her 9-year-old daughter, had been placed in the custody of Child Protective Services and replaced by an imposter.
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Green-Colored StoolThe parents of a 7-month-old girl brought their daughter for immediate medical attention after she passed bright green-colored stool. For the past 24 hours, the child had mild fussiness and a low-grade fever (temperature, 38.1°C [100.6°F]); she also had vomiting and mild diarrhea, with yellow-colored stools. The mother was advised to begin small, frequent feedings of oral rehydration solution with gradual return to the baby's normal diet, as tolerated. Over the next 12 hours, the vomiting and fussiness decreased and the fever resolved, but the mild diarrhea persisted and stools turned bright green. The parents denied giving the child green-colored drinks or food.
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Dog Bite in a Penicillin-Allergic PatientThe patient, a 14-year-old boy, comes to see you the same day he was bitten by a dog. In the examination room, you find him seated comfortably in the chair with his right hand and arm bandaged.
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Snakebite EnvenomationWhen reaching under a shed for the frog she had been chasing, a 4-year-old girl was bitten by “something.” The parents thought the bite was from a snake because of reports of copperhead sightings in the area. The mother immediately brought the child to the emergency department (ED).
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Keratoconus With Acute HydropsThis 14-year-old boy with autism presented with sudden visual loss in the right eye. For a week, the eye had been red, irritated, and painful. Three days earlier, "a white bubble" had developed on the cornea and had begun to obscure his vision.
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ADHD Medications: A Look at Their Safety ProfileEach year in this country, physicians prescribe medications to treat ADHD in nearly 3 million children. The safety of these agents has been the subject of some debate.
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Osteomyelitis Associated With Cat-Scratch DiseaseA 3-year-old girl was hospitalized because of purulent drainage from a right middle finger wound (Figure 1) and a tender right axillary mass (Figure 2) of 2 days’ duration.
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Case in Point: Infant With an "Atypical Mole"A 6-month-old infant was brought for evaluation of an "atypical mole" on the chest that her parents and referring physician feared might be skin cancer. The parents reported that the lesion had been present since shortly after birth and had become red and inflamed after minor trauma on a few occasions and once had blistered.
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Photoclinic: Tinea CapitisThe parents of a 3-year-old girl sought evaluation of their daughter's hair loss. During the past several months, a large patch of alopecia with scaling had developed. The differential diagnosis included seborrhea, trichotillomania, and tinea capitis. Joe R. Monroe, PA-C, MPAS, of Tulsa, Okla, writes that in seborrhea, scaling typically occurs throughout the scalp without the patches of alopecia seen in this patient. Broken-off hairs--a key to trichotillomania--were absent here. A potassium hydroxide preparation of scrapings that contained hairs from the affected area were positive for the "endothrix" phenomenon--the finding of fungal elements inside the hair shaft. Palpable, tender suboccipital lymph nodes were also detected. Both of these findings are common in tinea capitis and essentially confirm the diagnosis.
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Emergent Laceration ClosureDr Crane and Mr Schoonmaker, who were at the campground, write that an inordinate amount of highway traffic resulting from a local bikers' rally prevented them from transporting the patient to a medical facility. Emergent wound closure had to be performed with available materials. After the wound was flushed, a household cyanoacrylate adhesive, Krazy Glue, was used to close the laceration. To add lateral support and to reduce the risk of wound dehiscence, Dr Crane embedded hair trimmed from the patient's scalp into a second layer of glue. To replicate wound closure tape, the hair was applied perpendicular to the laceration. Azithromycin suspension was available; 1 tsp (5 mL) was given initially followed by 2.5 mL daily for 4 days.
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Two Teens With Retrosternal Chest Pain and OdynophagiaA previously healthy 14-year-old girl presented with retrosternal chest pain, odynophagia, and dysphagia of 10 days' duration. Her medical history was unremarkable. Results of an ECG and a chest radiograph were normal. An upper GI series revealed an abnormality at the level of the mid esophagus. She was treated with lansoprazole and sucralfate for a week; however, her symptoms persisted and perhaps worsened slightly. She lost 2.3 kg (5 lb) during her illness and was referred to a pediatric gastroenterologist.
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Genetic Testing for Autism: What Can Be Done, How Helpful Is It?In this podcast, Dr John Harrington of Eastern Virginia Medical School and Children’s Hospital of The King’s Daughters, and Dr Michael Paul, CEO and Rena Vanzo, Genetic Counselor of Lineagen-provider of a new integrated genetic testing and counseling service FirstStepDx-discuss the diagnosis of autism and genetic testing for autism.
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Cerebral Palsy: A Multisystem ReviewABSTRACT: Most cases of cerebral palsy (CP) are the result of congenital, genetic, inflammatory, anoxic, traumatic, toxic, and metabolic disorders. A minority of cases result from asphyxia at birth. Nearly three-quarters of children with CP aged 7 years had a normal neurological evaluation at birth. Abnormal motor development usually provides the first diagnostic clue. Neuroimaging is recommended if the cause of CP has not been established with perinatal imaging. MRI is preferred to CT. Management of the multisystemic manifestations begins with a comprehensive medical evaluation by a multidisciplinary team that includes family members. Therapy is aimed at maximizing the patient's level of function. Key areas include ambulation, cognitive skills, activities of daily living, hygiene, and rehabilitation into society.
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Podcast: 5 Myths About Office-Based Spirometry-and Why You Really Do Need This Essential ToolIn this podcast, Dr John Kelso dispels myths and makes a case for office-based spirometry for pediatricians.
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How to Interpret Office Spirometry (Part I): 5 Criteria for Interpreting Flow-Volume CurvesRegular spirometry to monitor lung function ensures successful asthma management-even in children. Here, a refresher for pediatricians on how to evaluate flow-volume curves.
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Pediatric Musculoskeletal Infections: Managing the Significant OrganismsMusculoskeletal infections in children include osteomyelitis, septic arthritis, and pyomyositis. Most of these infections are bacterial.
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Caterpillar StingWhile playing on a brick walkway in her backyard, a 4-year-old girl stepped on a puss caterpillar and was stung. The ecchymosis exactly outlined the caterpillar's spines and remained visible for at least 3 months. The initial sting caused intense pain that lasted for more than an hour.
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Newborn With Wrinkled Abdomen and Other AnomaliesPrune belly syndrome is a rare condition, classically referred to as a triad of abdominal wall musculature deficiency, bilateral cryptorchidism, and other urological abnormalities, although the clinical presentation can vary. A case history here.
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Apert Syndrome in an InfantAfrican American girl born at 36 weeks' gestation to 24-year-old primigravida via spontaneous vaginal delivery at a community hospital. Apgar scores, 7 at 1 minute and 9 at 5 minutes. Grossly normal placenta, with a 3-vessel cord. On the second day of life, infant required several minutes of blow-by oxygen for a desaturation event and subsequent transfer to a level III neonatal ICU for further monitoring.
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Case In Point: Pneumatosis Cystoides Intestinalis: An Unusual Radiographic FindingA 14-year-old girl was referred for evaluation of a several-year history of growth failure, chronic abdominal pain, and intermittent emesis. The parents described the child as a "picky eater," and various foods (eg, meat products and beans) frequently caused abdominal distention.
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Toddler With Progressive Proptosis From Acute Myelogenous LeukemiaA few days before presentation, the mother noted some "bumps" that had developed behind the child's right ear. The child was brought to the emergency department for evaluation.
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Torticollis and Fever: A Case of Grisel Syndrome From Group A Streptococcus InfectionA previously healthy 2-year-old boy was hospitalized after 2 weeks of persistent fever (temperature to a maximum of 38.9C [102F]) and a 2-day history of neck stiffness. There was no history of cough, rhinorrhea, or dysphagia. The oropharynx could not be examined because of neck stiffness. The patient had bilateral anterior cervical lymphadenopathy.
