PEM Source

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All posts with tag: "abuse"

PEM Questions

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You are seeing an 8-year-old boy for prolonged nosebleed last night and this morning. Last night it happened on the right nares, and this morning on the left nares. Dad is a nurse and held pressure until the bleeding stopped, and there is currently no bleeding. Exam shows temp 37.5, HR 90, RR 24, BP 94/56. Exam is negative for lymphadenopathy, hepatosplenomegaly, or pallor. There is a small amount of dried blood in the left nares. His parents did not notice any rash, but on exam with the patient undressed you notice a few petechiae on the ankles and across the lower abdomen. There are no purpura. Laboratory values are: WBC 10.3, diff 40% polys, 45% lymphs, 8% monos; Hgb 13, Hct 39, Platelets 1. Lytes, LFTs, BUN/Cr, are all normal. There are no inpatient beds available, so management will begin in the ED. 

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A 20 month old boy is brought in by his mother for refusal to bear weight on the right leg. She was at work all day and the child went to the park with his father, but no known trauma occurred. He has had no fever, URI symptoms, or rash. He was born full-term and has no significant past medical history. Physical exam of his right leg is unremarkable. AP and lateral X-rays are as shown. 

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A 6 month old female infant is referred in from PMD for concerns regarding the GU exam. Physical examinations at the 2 and 4 month old visits were normal. There are findings of concern for an STI. 

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(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old child has sustained an arm fracture. Per the parent, the 4 year old sibling was carrying the child and tripped. [yop_poll id="34"]
Of the following fractures, which is most concerning for non-accidental trauma? A. 18 month old brought in for refusing to walk, no history of any trauma or fall. Toddlerfx (source medscape) B. 18 month old brought in for refusing to walk, history of falling from a jungle gym approximately 3 feet off the ground. Cornerfx (source http://www.meddean.luc.edu/) C. Both are concerning for non-accidental trauma D. Neither are concerning for non-accidental trauma Check back in a few days for my answer and others' comments

Tips and Tricks

Here's a quick and dirty method to recall developmental milestones Development See the zero 0 as the "o" in tone, as the eyes for gaze, and as the mouth for strong suck The word two (months) is a combination of track and coo At four, the baby finds things funny (laughs) and pushes up on forearms to roll At six, the baby sits and makes sounds Picture the number 9 in a standing position and making a pincer grasp The w in twelve is for words and walks At 2 years old, the child has 2-word sentences and runs on 2 legs
Use a glass test tube or specimen tube to press on a rash to see if it blanches - remember, petechiae and purpura don't blanch. You can also use a glass test tube as a mini-anoscope to blanch surrounding mucosa and assist in identifying anal fissures in infants. (Anal fissures are one of the many possible causes of GI bleeding in children - check out pemplaybook.org's latest podcast on GI bleeding) glass_test-focus-none-width-800 (From https://www.meningitisnow.org/meningitis-explained/signs-and-symptoms/glass-test/)  

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