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All posts with tag: "derm"

PEM Questions

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Parents bring in their 11 month old baby for a new-onset rash. The baby is unimmunized by parent choice. The baby had fever for the last 3 days to a maximum of 104 F. Although he had fever, he was well-appearing and still eating normally and playful. But since the fever was persistent, they took him to a clinic yesterday and he was diagnosed with a throat infection and started on amoxicillin. He has received 2 doses. Today he awoke with a fine morbilliform blanching pink rash that started on the neck and trunk, then has spread to the face and extremities. It does not seem itchy and it does not involve the mucosa. The only other medication he has had was acetaminophen yesterday at 5pm. On exam, he is nontoxic and interactive. Vital signs: temp 98.9 F, HR 132, RR 28, O2 sat 99% on room air. ENT, chest, and abdomen exams are unremarkable. 

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You are seeing a 6 year old girl who comes in for right leg pain after a ground level fall at the park. She is currently being worked up by her pediatrician for precocious puberty, including vaginal spotting and breast buds. On exam, her temp is 37.5, HR 90, RR 22, pulse ox 100% on room air. Her face appears asymmetric. Heart and lung exam is normal. Abdomen is soft, and you do not palpate any masses. Her right leg shows no swelling, obvious deformity, or neurovascular compromise, but she is tender to palpation along her anterior tibia. She has a large light brown irregularly shaped macule on her back. 

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You are seeing a 14 month old who has a two irregularly oval yellow-tan lesions on his right upper arm, just under 1cm each. They have been present all his life and have grown slightly. Sometimes they seem to become acutely inflamed, and the boy has flushing and intense itching. 

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You are seeing a 3-year-old boy with 2 days of fever to a maximum of 102.7 F, an urticarial rash (but no enanthem), and significant arthralgias. The individual urticarial lesions are not transient, but rather present for more than 24 hours. He is not toxic but appears miserable. He was diagnosed with acute otitis media 8 days ago and is on day 8 of a 10-day amoxicillin course. 

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You are evaluating a 10 year old patient who had a bone marrow transplant 2 months ago. The patient is presenting with low-grade fever, a maculopapular rash on the nape of the neck, shoulders, palms, and soles as well as nausea, vomiting, and diarrhea. The patient owns a cat but is not involved in caring for it and does not have it sleep with him. 

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You are seeing an 18 month old girl with chief complaint of itchy scalp and rash at the nape of her neck just below her hairline. On examination, you note nits but do not see any live lice. The parents have not performed any treatments for lice. 

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It’s summertime, and you are seeing a 15 month old with fever and papulovesicular lesions on the palms, lateral borders of the feet and soles, and buttocks, as well as vesicles in the posterior pharynx. 

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You are seeing an 8 year old boy with the pictured lesion. He has had it for 2 months; it is slowly growing, and occasionally bleeds when irritated. It is not tender and he has no fever.

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You are seeing a 3 day old infant with a new onset rash on the chest and abdomen. The baby was born full-term with no complications and went home yesterday. Mom has been exclusively breastfeeding every 1-2 hours, and ate a bag of peanuts several hours before noticing the baby’s rash. The baby has no fever and is eating and urinating well. There is no history of maternal infections.

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You are seeing an 8 year old girl who was prescribed an oral cephalosporin antibiotic 1 week ago for rhinitis. She has 3 more days until she finishes the course. Now she has developed an itchy urticarial-like rash, although it is more fixed than urticaria typically are (does not move around nor come and go). She also has some generalized mild arthralgias and a low-grade fever to 100.2 F. 

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You are seeing a 10 month old infant with one day of fever, purpuric rash, and subcutaneous edema of bilateral extremities. He was seen in the ED one week ago for cough and congestion and diagnosed with a viral URI. At that time, COVID, influenza, and RSV were negative. On exam, his temp is 39.1. He has multiple, scattered, annular, sharply demarcated hemorrhagic plaques, mainly on his cheeks and bilateral extremities, lower > upper. He is otherwise well appearing and remainder of the physical exam is unremarkable. CBC including platelet count, CMP, coags, DIC panel, CRP, UA, and CSF were all normal.

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You are seeing a 3 year old ill-appearing child with high fever and rash. She initially started with tender erythema in her skin folds, progressing over the next 48 hours to diffuse erythema with flaccid desquamating bullae and yellow crusting around the eyes and mouth. Nikolsky sign is positive. There is no mucous membrane involvement. She was given ibuprofen at home after onset of the fever. 

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A 6 year old boy presents with 2 days of nontender palpable purpura of bilateral lower extremities, accompanied by arthralgia of the left ankle. Vital signs are temperature 37.6, HR 90, RR 20, BP 105/60. He has no nuchal rigidity. He has no significant past medical history. His CBC shows normal platelet count and PT/PTT are normal. 

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You are seeing a previously healthy 9-month old boy brought in for rash. The child had 3 days of fever. He was seen yesterday evening at an urgent care and diagnosed with otitis media and prescribed amoxicillin. He has never taken any antibiotics before. This morning, his fever was gone, but he developed a blanching pink maculopapular rash on the torso that spread to the extremities and face later in the afternoon. He does not seem to be itchy. He has been well appearing and eating normally throughout his illness. 

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 month old with a rash for 3 days. It started as fluid-filled vesicles that grew, burst, and released clear-yellow non-purulent fluid. It seems mildly itchy to the parent. The child has had a low-grade fever to 38.2 for one day and appears otherwise well. There is no past medical history and no ill contacts; immunizations are up to date. Bullous Impetigo Open access, Pereira LB - Anais brasileiros de dermatologia (2014 Mar-Apr) [yop_poll id="173"]
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(Click the link to comment and to vote - voting not working through email, sorry!) A 12mo old child with immunizations up to date presents with fever and rash. Which of the following distributions is concerning for measles? [yop_poll id="139"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a child with fever and rash x 1 day. Cognizant that we are in the middle of a measles outbreak, which of the following reassures you that this is unlikely to be measles? [yop_poll id="97"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19 year old otherwise well-appearing man presents with 2 days of headache, anorexia, tactile fever (but afebrile in the ED), and 1 day of palpable purpura on bilateral lower legs. Which of the following is true? [yop_poll id="92"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following topical antibiotics has the least efficacy against impetigo? (see pictures of impetigo here and a short article here) [yop_poll id="88"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child has a flat lesion of the entire left forehead and upper eyelid the color of light red wine that has been present since birth. The family has presented to the ED because they are concerned that the child has right sided weakness.   sturge-weber-1 https://mindfulmema.wordpress.com/tag/sturge-weber/ [yop_poll id="64"]  
(Click the link to comment and to vote - voting not working through email, sorry!) A 6yo girl presents with palpable purpura of both legs for 2 days. She has not had any fever and is well appearing. Her labs, including CBC, electrolytes, BUN, Creatinine, and ESR are normal. She does not complain of any pain. Her vital signs are temperature 37.5 C, HR 90, RR 20, BP 90/45. She has no abdominal tenderness, vomiting, respiratory difficulty, joint pain or swelling, and her urination has been normal. Her stool guaiac is negative. [yop_poll id="62"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17yo boy presents with a round lesion similar to that noted below, but on his penis, noted 1 hour after taking a dose of TMP-SMX that was prescribed to him for “stomach infection.” He had 2 episodes of non-bloody diarrhea 2 days ago and went to a clinic and received the prescription, which he was unable to fill until today. The diarrhea has actually improved. He has no fever. The rash is not painful or itchy. He mentions that he previously had a similar rash in the same place after taking the same drug a few years ago. Fixed drug eruptionWikimedia Commons Donald M. Pillsbury, M.D., and Clarence S. Livingood [yop_poll id="60"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 9 month old baby is brought in with this problem, first noted a few hours prior. Hair tourniquet By James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons [yop_poll id="55"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old is brought in because all of his fingernails and toenails are falling off, painlessly. On review of the ED electronic medical record, he was seen 6 weeks ago and diagnosed with a viral infection. What viral infection did he have? [yop_poll id="38"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is true about erythema multiforme major, Stevens-Johnson syndrome, and toxic epidermal necrolysis? [yop_poll id="17"]
Impetigo http://diseasespictures.com/ What is the best treatment for this 3 year old patient’s rash? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="14"]
A family obtained tuna from the local farmer’s market and prepared it for dinner. The children thought the fish tasted weird, peppery or metallic, but the parents did not, and told the children to stop complaining and eat dinner. Within 20 minutes of consumption, the children complain of headache, dizziness, pruritis, abdominal cramping, and nausea. They appear somewhat flushed in the face, neck, and chest. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="12"]
A 10yo girl comes home from a family vacation to Florida in June, where she swam in the ocean. She has an itchy rash in the area covered by her bathing suit that started soon after swimming in the ocean and is still present 3 days later. Seabathers   http://www.medicinenet.com (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="6"]

Tips and Tricks

Managing parent expectations is half of pediatric emergency medicine. When parents bring in kids with worsened eczema (either as a chief complaint or a side complaint), they are often frustrated that they used the prescribed cream, things got better, but now the rash is back. I like to explain that eczema is like “asthma of the skin,” and to expect “attacks” or “flares” just like asthmatics get, depending on environmental pollen counts, dry air, etc. When an asthmatic has a flare, they use their albuterol inhaler, and when someone with eczema has worsened rash, they ramp up their dry skin regimen and use steroid creams. Lately I’ve also been comparing hand-foot-mouth to “a virus in the chickenpox family” with similarities that it has to get better on its own, antibiotics don’t help, and it takes 7-10 days for the lesions to heal up.

Here’s a great tip from one of our PEM fellow’s recent lectures. When a patient has cellulitis that’s being treated as an outpatient, we often outline the area of erythema with a pen so the parent can know if the cellulitis spreads further. Another tip to follow the progression of rashes in general is to ask the parent to take a photo with their smart phone and bring it to the follow-up PMD or ED visit.

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/)  
Measure your fingernails to see which is closest to 1cm - now you will always have a 1cm "ruler" with which to measure lesions, lacerations, discolorations, etc. Measure nail  

Controversies

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="34"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a patient with a simple small abscess and no or minimal overlying cellulitis, nontoxic and afebrile, immunizations up to date, no prior abscesses. After successful incision and drainage, what treatment would you give? [poll id="27"]

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