PEM Source

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All posts with tag: "renal"

Tips and Tricks

Hypertensive urgencies and emergencies can be missed in kids when physicians are used to the elevated BP’s of adults with essential hypertension. Hypertension in children is defined relative to the 95th percentile for age & sex. BP > 90th percentile is elevated; Stage 1 hypertension is a BP from the 95th percentile to 95th + 12 mm Hg. Stage 2 hypertension is a BP > the 95th percentile + 12 mm Hg (or > 140/90 for > 13yo). Stage 1 and asymptomatic Stage 2 patients should be referred back to the PMD for confirmation of repeated elevated BPs and outpatient work-up. Hypertensive emergency is a Stage 2 patient with evidence of end-organ damage, e.g. seizure, stroke, altered mental status, papilledema, heart failure, or a BP > the 95th percentile + 30 mm Hg, even if asymptomatic. Charts can be used to determine the 90th and 95th percentile, but a rule of thumb is that 95 + 2 (age in yrs)/50 + 2 (age in yrs) = the 90th percentile, and 115 + 2 (age in yrs)/65 + 2 (age in yrs) = Stage 2 hypertension. (Source: MacNeill E. Pediatric Emergency Medicine Practice, March 2019)

A trio of recent publications on pediatric UTI offer some insights. First, Mattoo et al offer a review of UTI diagnosis and management in children. Nadeem et al studied the optimal WBC cutoffs for diagnosing UTI, balancing overdiagnosis/overtreatment with underdiagnosis/missed UTIs, based on the specific gravity and found them to be: 3 WBC/hpf for spec grav < 1.011, 6 WBC/hpf for 1.011-1.020, and 8 WBC/hpf for spec grav > 1.020. And Liang et al reviewed 2144 PED visits in < 2yo and calculated likelihood ratios and posttest probabilities for various urinalysis findings. UTI prevalence was 9.2%, which the authors used as the pretest probability. Likelihood ratios for leukocytes were: 1+ 2.79. 2+ 7.53, 3+ 37.68. Nitrite positivity carried a LR of 25.35. WBC/hpf at 5-10 had a LR of 1.2 (95CI 0.7-2.04), 10-20 LR 1.82, 20-50 LR 11.18. Few bacteria had an LR of 1.46, moderate 6.05, many 14.04. 

PEM Questions

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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 15yo girl with a strong family history of nephrolithiasis who presents with colicky right flank pain, non-bloody non-bilious vomiting twice, and microscopic hematuria. Her UA results do not support a diagnosis of UTI or pyelonephritis. She is not sexually active. She was seen in the ED 6 months prior for RLQ abdominal pain and underwent a CT scan which was negative for appendicitis or any other pathology. She describes the current pain as different from the pain she had 6 months ago. After IV fluids, ketorolac, and morphine therapy her pain is improved.

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2 year old who is slowly improving from a bout of acute gastroenteritis manifested by fever, vomiting, diarrhea, and abdominal pain that started 5 days ago. The parent is concerned that he remains less active and appears pale. Vital signs are temperature 37.7, HR 135, RR 24, BP 110/60, O2 sat 99% on room air. Point of care hemoglobin is 6.5 g/dL. [yop_poll id="155"]
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(Click the link to comment and to vote - voting not working through email, sorry!) You have diagnosed a 14 year old boy with likely nephrolithiasis, as evidenced by his colicky flank pain, hematuria, and ultrasound showing mild hydronephrosis. [yop_poll id="115"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8yo boy presents with a 1 month history of progressive periorbital and generalized facial swelling, worse in the morning. Urine dip is positive for proteinuria. You suspect nephrotic syndrome. [yop_poll id="108"]
(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"]

Controversies

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Note: controversies 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!

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(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! Parents bring a 15mo old non-black uncircumcised well-appearing fully immunized male with 3 hours of fever and no other symptoms. His temperature is 39 C. You find no clear source for the fever on exam. It is wintertime and his siblings all have URIs but this patient has no cough or congestion. He has not had any prior UTIs. Do you catheterize him for urine to rule out UTI? [poll id="45"]

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