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PEM Questions

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You are seeing a 12 year-old with 2 weeks of nasal congestion, rhinorrhea, sneezing, and sore throat, especially in the mornings. She has had no fever. On exam, her nasal turbinates are pale and boggy. She has a horizontal crease below the bridge of her nose and her lower eyelids are bluish and puffy.

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You are seeing a 3 year old child with acute onset draining right ear. The child has no fever and no history of recent swimming or other risk factors for otitis externa. The child has a PMH of frequent otitis media, and pressure equalization (tympanostomy) tubes were placed at age 1 year. There have been no episodes of otitis media since then. As far as the parents know, the tubes are still in place, but they have not had any follow-up with an ENT. On exam, the left ear canal has a PE tube laying in the canal, which you remove; the tympanic membrane is translucent and mobile. The right canal is full of seropurulent drainage. You cannot see the tympanic membrane nor any PE tube. The canal itself is not swollen or red. 

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(Click the link to comment and to vote – voting not working through email, sorry!) A 2yo child presents with a 1.5cm diameter erythematous tender fluctuant swelling in the right preauricular area. There is a small pinhole sized indentation in the center. Which of the following is not appropriate management? [yop_poll id="148"]
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Match the child with acute otitis media to appropriate therapy per AAP guidelines (all children well-appearing, non-toxic, no distress or indications of severe otalgia, symptomatic for 1 day, and have not had recent antibiotics in the last 30 days):

Child A) 5mo old with bilateral otitis media, afebrile

Child B) 18mo old with unilateral otitis media, fever to 38.5, penicillin-allergic

Child C) 27mo old with bilateral otitis media and bilateral purulent conjunctivitis and fever to 39.1

Child D) 37mo old with unilateral otitis media, fever to 39.5, penicillin-allergic

  1. Oral analgesic
  2. Amoxicillin 90 mg/kg/day divided BID
  3. Amoxicillin-Clavulanate 90 mg/kg/day divided BID
  4. Cefdinir 14 mg/kg/day
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(Click the link to comment and to vote - voting not working through email, sorry!) Bullous Myringitis [yop_poll id="138"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is/are true of bacterial tracheitis?
  1. Children presenting with bacterial tracheitis tend to be older than children presenting with viral croup
  2. Children with bacterial tracheitis do not respond as well to racemic epinephrine and steroids as children with viral croup
  3. Children with bacterial tracheitis may have a “steeple sign” on xray
  4. Children with bacterial tracheitis most commonly have Strep pneumoniae infection
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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 16 year old boy with sore throat, worse on the left side, dysphagia, low-grade fever, difficulty fully opening jaw (trismus), and muffled voice. You diagnose peritonsillar abscess and plan to perform a needle drainage procedure. [yop_poll id="118"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="104"]
(Click the link to comment and to vote - voting not working through email, sorry!) About 70% of ear infections improve spontaneously. Which of the following patients is NOT a candidate for the “wait and watch” no-antibiotics option (for all patients assume well appearing otherwise)? [yop_poll id="83"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 10-year old child is brought in for swelling that developed 2 hours ago around the mouth as well as a sensation of difficulty swallowing and breathing. Vital signs are normal and she is not hypoxic nor stridorous, but she does have right sided perioral swelling as well as mucous membrane swelling. There is no discoloration. She has no urticaria, pruritis, nor hypotension. She had dental work on her right lower teeth the day prior, and had local anesthetic injection for that. She took one dose of acetaminophen the day prior and one dose 6 hours ago. Her stepfather gave her diphenhydramine 1 hour ago, but it hasn’t helped. The child denies trauma and says that she felt tingling in the area for 1 hour prior to the onset of swelling. [yop_poll id="81"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing an 8 month old child with viral URI symptoms and pulling at the left ear. The child has not had any fever, is fully immunized, and is well appearing and playful. The right ear is translucent. The left ear is erythematous, with no bulging, perforation, or air-fluid level. Mobility is normal on pneumatic otoscopy. The child had one previous ear infection diagnosed at age 5 months. [yop_poll id="47"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old child with cochlear implants placed 8 months ago. The child has fever, headache, vomiting, altered mental status, and meningismus. The implant sites are well healed and show no signs of local infection. [yop_poll id="46"]
(Click the link to comment and to vote - voting not working through email, sorry!) A previously healthy 5 year old boy with PMH of ADHD presents with 9 days of lethargy, fever, vomiting, diarrhea, and weight loss. He recently was diagnosed with strep pharyngitis and treated with amoxicillin for 3 days. His vital signs are: temp 39 C, HR 140, RR 24, BP 154/99, O2 sat 99% on room air. His exam is significant for agitation and restlessness, and tachycardia with bounding pulses and a hyperdynamic PMI. His mother feels that his anterior neck looks swollen. [yop_poll id="23"]
Impetigo 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 17yo boy comes in with complaint of inability to breathe from the right nares. He was seen 2 days ago by his PMD and prescribed amoxicillin for sinusitis, but is not improving. He denies placing any foreign body in his nose. He was in an altercation at school and was hit in the nose 4 days ago. Which of the following would be the most appropriate treatment of this patient’s condition? Septal hematoma A. Change antibiotics to amoxicillin-clavulanate B. Attempt removal of foreign body C. Incision and drainage and nasal packing D. Referral to otorhinolaryngologist for polyp removal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
You are seeing a 12yo child with right ear pain for 2 days. He has been swimming recently. On examination, he has pain when you pull on the pinna of the ear to straighten the canal, and the canal is swollen and full of purulent discharge. He is afebrile and has no previous history of ear infection. Which of the following is FALSE regarding the management of this patient? A. Systemic antibiotics play no role B. If the patient had a history of pressure equalization tubes, neomycin + polymyxin B + hydrocortisone (cortisporin) drops would be contraindicated C. The patient should be advised not to swim while undergoing treatment D. Pain can be treated with antipyrine + benzocaine (auralgan) drops E. Fluoroquinolone drops are the most commonly used antibiotic therapy
A 17yo boy presents with severe sore throat for two days, and fever to 39. He has difficulty swallowing due to pain. He has no cough, congestion, nor ill contacts. His immunizations are up to date. On examination, he is alert, has no respiratory distress or stridor. His oropharynx has 2+ tonsils which are somewhat red, no exudate, no vesicles, no peritonsillar swelling. He has tender cervical lymphadenopathy and is very tender on palpation of his anterior neck at the level of the hyoid bone. The most appropriate management is: A. Obtain lateral neck X-ray in the ED and consult ENT specialist B. Consult ENT specialist to intubate the patient in the O.R. C. Give dexamethasone and penicillin-benzathine and discharge home D. Recommend supportive care for a viral URI E. Obtain a CT scan to evaluate for deep neck infection
A 2 year old is brought in that has chewed on an electrical cord. He has a scab in the corner of his mouth and no active bleeding and is otherwise well appearing with no other trauma. What delayed complication can occur?

Tips and Tricks

When treating otitis externa, placement of an ear wick can help direct topical antibiotics into a swollen canal. If you don’t have a commercially sold ear wick, you can make one by cutting a small strip of merocel or even ribbon packing gauze (~15mm is a typical length). This video explains insertion. At least 6 drops of oto-antibiotics should be placed on the external end of the wick to prime it, and the patient should then be instructed to continue applying 2-4 drops to the external end of the wick 2-4x/day. The wick should be removed after 2-3 days. If insurance doesn’t cover otic fluoroquinolone drops, ophthalmic fluoroquinolone drops can be used in the ear (but vice versa is not true). If the canal is so swollen that it’s hard to get the ear wick in, use a small well tapered otoscope speculum to direct steroid otic drops into the canal first to decrease swelling.

My husband the internist likes to say that we peds MDs are pretending to see the TM, but I say the MDs for adults are pretending to hear diastolic murmurs. Kidding aside, you really can get good at seeing TMs in kids - a useful skill since 60% of kids will have AOM by age 4 years. Tip 1: Positioning: my most successful position is with the child sitting on parent’s lap, turned 90 degrees to one side, legs held between the parent’s legs, parent restraining child with a “hug”. Rotate the child 180 degrees to face the other way to look at the other ear. Even though the below picture shows a child getting a shot, this is the basic positioning. Don’t let the child face forward, make sure they are turned to the side. Ear Exam PositionDHS Comforting Restraint for Immunizations 2001 Tip 2) Specula: Our ED has just two size specula – 2.75mm “pediatric” and 4.25mm “adult”. If the child is 1yo or more, start with the larger specula. You can always go down in size if it’s too big or you need to push through or around wax. Don't be afraid to push the speculum in a bit - it is tapered so you are unlikely to reach the tympanic membrane with the tip. Tip 3) Otoscope: Grasp the helix of the ear and pull posteriorly and slightly outwards. Brace the fingers of your otoscope hand against the patient’s cheek so you can move with the child if he moves. Angle the speculum anteriorly as you enter – a common pitfall of trainees is seeing only the canal because the TM is angled more anteriorly in a young child. The best visual I could find of this positioning is a screen grab from the video below: Ear Exam Position 2 Regarding the video, to examine the patient's left ear, I prefer to keep the otoscope in my right hand and bring my left hand up and over the ear to pull on the helix, rather than switch hands    
Some tips and tricks for examining children's throats:
  1. Don't do it until after you've gotten your lung, heart, and abdomen exam - once you make them cry, it's game over
  2. A helpful position for young children is to sit on the parent's lap facing the parent, legs straddling the parent. Then, have the parent lean the child back so he/she is laying supine on the parent's knees with the head hanging back (the dentist chair view)
  3. Older children can be asked to pant like a dog, scream, or sing "ah ah ah ah ah" opera-style
  4. Sometimes if you do the ear exam first, the child will yell and then you can see the throat
The Katz extractor is a great tool for removing nasal foreign bodies, as shown on the video here (I have no financial interests in this product). But, if you don't have one available, get a Fogarty cardiac embolectomy catheter from the O.R., and this will do nicely as well. For many many tips and tricks on removing foreign bodies in the head and neck, go to PEMplaybook
Cut a narrow caliber ETT short to create a semi-rigid suction catheter for foreign body removal of the nose or ears.  (From EM News September 2009, Tricks of the Trade: An Improvised, Semi-Rigid, Nasal/Aural Suction Catheter, by Timothy McGuirk DO)
Use a laryngoscope upside down as a tongue blade, or use a self-lighting pelvic exam speculum (remove top half of the speculum)


(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! A 7 year old boy presents after injuring his lateral soft palate with a straw. He is completely asymptomatic and exam other than what is shown is normal. Palate injury [poll id="42"]
You are seeing a 35 month old boy with fever and sore throat x 2 days. He has no cough or runny nose, but his sister also had fever and sore throat recently, and his mom has a cough. His temp is 38.5. He has no tonsillar exudate or palatal petechiae, and only tender cervical lymphadenopathy. He is otherwise well appearing, previously healthy, and is well hydrated. [poll id="6"]
Nearly 3 year old girl was eating nuts and had a coughing episode. 6 year old sibling told parents "she's choking on the nuts." In the ED, patient is completely asymptomatic, has a normal CXR and a 100% O2 sat on room air. [poll id="7"]

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