PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "id"

PEM Questions

(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 5 year old was bitten by the family cat superficially on his right index finger, 3 days ago. He presents now with redness, warmth, and pain over the volar aspect of his index finger. [yop_poll id="31"]
(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]
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"]
You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]
A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]
A 16yo girl presents to the ED with symptoms and rash consistent with varicella (chickenpox). She was never vaccinated, as a personal family choice. She also recently gave birth. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="5"]
A 10yo boy obtained a pet rat from a commercial pet store. Upon returning home, his new pet promptly bit him. 5 days later, he has fever, chills, severe headache, polyarthralgias, and a maculopapular rash with some petechiae that developed after 2 days of fever. What organism is the most likely cause for the boy’s symptoms? A. Staphylococcus aureus B. Group A Streptococcus pyogenes C. Eikenella corrodens D. Rabies virus E. Streptobacillus moniliformus
Which of the following wild animal exposures is the lowest risk for rabies?
  1. Skunk
  2. Coyote
  3. Raccoon
  4. Fox
  5. Rabbit
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
Which of the following is true about Clostridium difficile? A. It is the most common cause of antibiotic-associated diarrhea B. The treatment of choice for C. diff colitis is IV vancomycin C. Asymptomatic carriage in children < 1 year old is common D. A and B E. A and C

Conundrums

(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 repeat - since we are in the throes of influenza season right now, and this is a particularly controversial issue. Many emergency medicine FOAM bloggers have argued against the use of oseltamivir, such as here. But, the CDC continues to recommend it for high risk patients presenting with < 48 hours of symptoms, citing their reasoning here. To complicate things further, the "definition" of influenza-like illness basically includes nearly all kids seen in the ED in the wintertime - fever and cough or sore throat, and point-of-care tests are not very sensitive. [poll id="19"]
(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! Got this one from a recent EM physician facebook group post. You see a mother with symptoms of influenza. Her 3 day old asymptomatic full-term infant is tested and is POC influenza+. There is good follow-up and the patient is healthy, afebrile, feeding well, etc. [poll id="22"]
(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 10 week old infant with a 38 degree fever of 6 hours duration. He has mild rhinorrhea as does Dad. He is otherwise well and feeding well. Point of care RSV and influenza are negative, and urine shows no pyuria or bacteriuria. Review of the chart shows mom was GBS+ and was treated with intrapartum penicillin as recommended. Baby was observed for 2 days in the nursery but not treated with antibiotics. [poll id="21"]
(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="19"]
A 2 month old was seen in the ED 36 hours ago with a temperature of 39.2. The CBC had a WBC of 11.2 with 70% lymphocytes and no bandemia. Urinalysis was negative. The lab calls you to report that 1 of 2 blood culture bottles is growing gram positive cocci in clusters. You call the patient and the parent reports that he is doing well, is now thought to be afebrile (tactile, parents have not checked the temperature in 24 hours), and is feeding well. What do you do? (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="18"]
You are seeing a 6 year old with a wet-sounding cough for 4 days and fever to 39 C for 3 days. You hear crackles in the right lower lobe; there is no wheezing. CXR shows no infiltrates. Do you diagnose a "clinical pneumonia" with false negative CXR and treat with antibiotics? [poll id="10"]
Vote! But for something other than President... You are seeing a 3mo old with clinical bronchiolitis who is otherwise well-appearing, tolerating po's, not in significant respiratory distress, afebrile, has good follow-up. At what O2 sat do you admit the patient for supplementary O2? The AAP says: aap-bronchiolitis-o2-sat [poll id="9"]
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"]
You're seeing a febrile well-appearing 29-60 day old with clear lab evidence of UTI and benign CBC. Do you do an LP? Do you admit and do you give parenteral antibiotics? What about for a 61-90 day old?

Tips and Tricks

Placing topical anesthetic (EMLA, LMX4) on skin abscesses may result in spontaneous drainage, precluding need for incision. If topical anesthetic doesn't result in spontaneous drainage, it at least provides some skin anesthesia prior to local anesthetic injection for incision and drainage procedure. In one published retrospective study, 26 of 110 patients with the topical anesthetic LMX4 placed had spontaneous drainage, 3 of whom required no further intervention: https://www.ncbi.nlm.nih.gov/pubmed/21129885
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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