F. RICHARD BRINGHURST, MD

• Senior Vice President for Medicine and Research Management,
• Massachusetts General Hospital
• Associate Professor of Medicine,
• Harvard Medical School, Boston

Patients with outflow tract obstruction usually have left ventricular hypertrophy medications not to be taken with grapefruit cheap disulfiram 250 mg without a prescription. If a patient has benign cause for chest pain medicine review cheap disulfiram 500mg overnight delivery, reassurance medicine quotes cheap 500mg disulfiram with visa, rest medications equivalent to asmanex inhaler buy disulfiram with a mastercard, and supportive care with use of acetaminophen or nonsteroidal antiinflammatory drugs is advised denivit intensive treatment buy disulfiram 250mg amex. When should a pediatric patient with chest pain be referred for urgent evaluation to an emergency department Exertional syncope and/ or palpitations with chest pain are some of the features that guide toward need for emergent referral to a tertiary center medications and mothers milk 2014 buy disulfiram mastercard. When can a patient with chest pain be referred for nonemergent outpatient evaluation by a cardiologist Patients with exertional chest pain that resolves with rest without signs of life-threatening arrhythmia can be referred for outpatient cardiac workup. Patients with exertional chest pain should be refrained from sports and gym until seen by a pediatric cardiologist. Those with benign etiology of chest pain should not be refrained from physical activities as this will create unnecessary anxiety in family and patient. Chest pain associated with exertion warrants careful evaluation for a cardiopulmonary etiology. Myocarditis and pericarditis in the pediatric patient: validated management strategies. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology. Noncardiac chest pain in children and adolescents: a biopsychosocial conceptualization. A 10-year-old male patient presents to your urgent care center with 2 days of generalized abdominal pain, associated with nonbilious vomiting and decreased appetite. It is responsible for 3% of all primary care visits for children and up to 25% of pediatric gastroenterology visits. Constipation can be broadly defined as infrequent bowel movements with at least one of the following: painful defecation, hard stools, purposeful fecal retention, fecal soiling, encopresis. Outside the neonatal period, childhood constipation is common and almost always functional without an organic etiology. A child typically presents with a chief complaint of hard pelletlike stools, difficulty or pain with defecating, abdominal pain, abdominal distension, vomiting, or anorexia. Functional constipation is commonly caused by painful bowel movements prompting the child to withhold stool. To avoid a painful bowel movement, the child will contract the anal sphincter and/or gluteal muscles, leading to stool retention, prolonged fecal stasis with reabsorption of fluid, and then a harder, larger stool that is more painful to pass. This cycle may occur with toilet training, changes in routine or diet, stressful events, illness, lack of accessible toilets. A history and physical examination are usually sufficient to distinguish functional constipation from constipation with an organic etiology. A history should review the frequency, consistency, and size of stools; age of onset of symptoms; meconium passage after birth; recent stressors; prior history and therapies; presence of withholding behaviors, pain, or bleeding with bowel movements; abdominal pain; and fecal incontinence. Physical exam should include an abdominal exam; external examination of the perineum, perianal areas, thyroid, and spine; and a neurologic evaluation for appropriate reflexes (cremasteric, anal wink, and patellar). What diagnosis must be considered in a neonate or infant presenting with constipation, poor feeding, and a weak cry Infant botulism is characterized by constipation followed by neuromuscular paralysis or "floppiness. In a child presenting with constipation since birth, what disorder must be considered Infants and children often with history of constipation since birth or delayed meconium passing (>48 hr) may have Hirschsprung disease. Children diagnosed later in childhood may have a history of poor growth, severe recalcitrant constipation, and intermittent vomiting. Physical exam may present with signs of enterocolitis, abdominal distension and pain, poor feeding, and foul-smelling watery stools. A digital examination is recommended to assess for perianal sensation, anal tone, rectum size, anal wink, rectal stool load, and consistency. Children with normal neonatal courses or clear withholding behaviors may have the rectal examination deferred. The presence of a hard mass in the lower abdomen and/or a dilated rectum with hard stool indicates fecal impaction. Abdominal radiography is not recommended for diagnosing constipation due to lack of interobserver reliability and accuracy, but it may be useful to determine the extent of fecal impaction. It can be used for specific clinical circumstances in which a rectal examination is unreasonable (child with history of trauma) or the diagnosis is uncertain. When fecal impaction is present, oral or rectal disimpaction is required before the initiation of maintenance therapy to keep the rectum empty and allow the rectum to return to its normal size. Parental education, behavior modification, and close follow-up are essential to prevent reoccurrence. If an organic cause is found, treatment involves addressing the underlying organic problem. Rectal therapies and polyethylene glycol are similarly effective in the treatment of fecal impaction in children. Oral therapies include osmotics (polyethylene glycol, magnesium citrate), stimulants (senna bisacodyl), and lubricants (mineral oil). Rectal agents include enemas (mineral oil, phosphate, normal saline) and suppositories (bisacodyl, glycerin). Studies show addition of laxatives is necessary and more effective than behavior modification alone. Recent studies show addition of enemas to oral laxative regimens does not improve outcomes in children with severe constipation. Polyethylene glycol achieves equal or better treatment success than other laxatives such as lactulose or milk of magnesia. Chronic abdominal pain, bowel obstruction, rectal fissures, enuresis, encopresis, urinary retention, urinary tract infection, rectal prolapse, and social stigmata are all possible complications. Appendicitis is the most common surgical condition in children who present with abdominal pain. Lymphoid or fecalith obstructs the appendiceal lumen, and the appendix becomes distended with ischemia and necrosis developing. Nearly 100%, due to the difficulty in localizing abdominal pain in nonverbal children. Many cases present similar to other common pediatric diagnoses such as constipation and gastroenteritis. Patients with appendicitis classically present with visceral, vague, poorly localized, periumbilical pain. Within 6 to 48 hours, the pain becomes parietal as the overlying peritoneum becomes inflamed; the pain then becomes well localized and constant in the right iliac fossa. Pushing on the abdomen in the left lower quadrant elicits pain in the right lower quadrant. Pain on passive extension of the right thigh with the patient lying on the left side. What is the radiographic diagnostic study of choice for diagnosing pediatric appendicitis Watchful waiting and serial abdominal examinations now have a significant role in diagnosing pediatric appendicitis. In a male patient presenting with localized abdominal pain, why should the genital area always be examined The male scrotum and testes should always be examined to rule out testicular torsion/pathology and inguinal hernias. Referred abdominal pain may occur due to the stomach and small intestine having shared innervation with the testicle and epididymis. What surgical emergency needs to be considered when an adolescent male presents with vomiting, abdominal pain, and a swollen, painful testicle Testicular torsion, a surgical emergency, presents with excruciating pain, scrotal swelling, nausea, and/or vomiting. Torsion is caused by the twisting of the spermatic cord, resulting with compression of the testicular artery and reduced or absent blood flow to the testicle. Presents in adolescence with 90% of cases due to congenital malformation, lack of proper fixation of the testis and epididymis to the scrotum, or the "bell-clapper deformity. A torsed testicle is typically tender, with scrotal swelling, erythema, or discoloration. The probability of testicular torsion is high with an absent ipsilateral cremasteric reflex. Diagnosis and treatment within the 6-hour time period is optimal to minimize the risk of testicle necrosis and loss. However, testicular torsion is a clinical diagnosis, and surgical exploration should be done when suspicion is high despite imaging studies. Bedside manual detorsion may be attempted as long as definitive treatment is not delayed. In a younger child, the pain could be nonspecific and difficult to localize or describe. Severe symptoms, such as acute abdominal pain, or tenderness, fever, vomiting, and pallor, can mimic an acute surgical abdomen. Risk factors include ovarian cysts or masses, pregnancy, and history of pelvic inflammatory disease. What is the study of choice to differentiate ovarian torsion versus other ovarian processes Findings for ovarian torsion may include enlarged unilateral ovary, a heterogeneous mass, absent arterial flow, or fluid in the cul-de-sac. Ultrasound assists in detection and diagnosis of other etiologies such as ovarian cyst, tubo-ovarian abscess, ectopic pregnancy, or appendicitis. Surgical or gynecologic urgent referral or transfer should be initiated immediately. Definitive treatment is surgical with laparoscopic or open detorsion with ovariopexy of the viable ovary. Pain may radiate to right shoulder, back, or flank with nausea and vomiting after eating fatty foods. Gallstones are rare in children, but recently the incidence of pediatric gallbladder disease has been increasing, paralleling the rise of obesity in children. A large number (40%) of children with gallstones are asymptomatic, and complications arise when stones obstruct the cystic duct (cholecystitis) or common bile duct (choledocholithiasis) or cause an infection of the common bile duct (cholangitis). Gallbladder distension, wall thickening, pericholecystic fluid suggesting choledocholithiasis, and stones as small as 2 mm can be visualized. The most common type of stone is the black pigment stone, which forms with excessive bilirubin in the bile. The prevalence of gallstones is higher in children with chronic diseases such as hemolytic anemia or sickle cell disease. Removal of the gallbladder in asymptomatic children with cholelithiasis is not standard practice, with the exception of those with sickle cell anemia. Laparoscopic cholecystectomy is the standard in the treatment of symptomatic cholelithiasis. It has been proven to be safe and effective in children, with a low rate of postoperative complications. Ill-appearing patients likely suffering from biliary stone complications should be stabilized with analgesics, antiemetics, and antibiotics and transferred/admitted. Patients with unresolved biliary colic, or any suspicion of cholecystitis, choledolithiasis, cholangitis, or pancreatitis should be referred and admitted. Blunt trauma to the pancreas is the most common cause of acute pancreatitis in children. Traumatic pancreatitis can result from motor vehicle accidents, bicycle handlebar injuries, and inflicted injury from child abuse. The diagnosis is clinical and depends on the presence of symptoms consistent with acute pancreatitis, abnormal blood tests, or radiographic images. A diagnosis can be made if two or more of these criteria are fulfilled: symptoms consistent with acute pancreatitis (abdominal pain, nausea, vomiting, and abdominal tenderness), elevated lipase and/or amylase, and imaging consistent with pancreatitis. Ultrasound is the imaging of choice for acute pancreatitis, as it can assess the pancreatic size, inflammation, and texture. It can also assess biliary stone obstruction and presence of pseudocysts or abscesses. The treatment of pancreatitis is supportive care with pancreatic rest, no oral intake or low fat elemental diet, fluid resuscitation, pain medication, and parenteral nutrition if unable to eat. Meperidine (Demerol) is preferred to morphine for pain control because it is less likely to cause spasm of the sphincter of Oddi, which can worsen the pancreatitis. Hepatitis may result from both infectious (viral, bacterial, fungal, and parasitic organisms) and noninfectious (medications, toxins, and autoimmune) causes. Possible viral exposures include blood transfusions, intravenous or intranasal drug use, sexual or sexual abuse history, and travel history. The most common symptoms of acute hepatitis include flulike symptoms, fever, abdominal pain, nausea, vomiting, fatigue, anorexia, jaundice, myalgias, dark urine, and clay-colored stools. Medications are not routinely given for treatment of uncomplicated acute viral hepatitis. Patients with evidence of fulminant hepatitis, hepatic encephalopathy, significant vomiting, dehydration, or electrolyte abnormalities require hospital admission.

Incision and drainage is always the first-line therapy for easily accessible lesions although warm compresses and antibiotics are intermittently used for enclosed abscesses medicine while pregnant buy disulfiram toronto. Erysipelas and cellulitis present with the triad of erythema medicine shoppe locations 250mg disulfiram overnight delivery, edema medications blood thinners order disulfiram 250 mg, and pain and are distinguished by depth of infection medications kidney disease purchase disulfiram with paypal, with cellulitis involving the subcutaneous tissue symptoms 3 days after conception generic disulfiram 500 mg free shipping. Diagnosis is made clinically medicine 9 minutes generic 250mg disulfiram, and treatment usually includes a first-generation cephalosporin or macrolide. Pitted keratolysis, or "sweaty sock syndrome," presents as hyperhidrosis, malodor, and a general sliminess of the skin, with general pitting of the soles of the feet as a classic distinguishing feature. Diagnosis is clinical, and treatment always commences with frequent drying, use of moisture-wicking synthetic socks, and antibiotic therapy with topical erythromycin or clindamycin. These lesions can be diagnosed under a Wood light examination with coral-red fluorescence. Multiple treatments have been used including topical and/or oral erythromycin or clindamycin, topical miconazole, oral clarithromycin, and red-light photodynamic treatment. Return to play guidelines are the same for most of the bacterial dermatoses and range from 48 to 72 hours of systemic antibiotics with no moist, oozing, or exudative lesions and no new onset of lesions in the past 48 hours. These infections require prompt treatment and monitoring as they will often progress to an abscess. Incision and drainage of any accessible abscess are usually recommended in addition to presumptive, systemic antibiotics. Trimethoprim-sulfamethoxazole and doxycycline are first-line agents, and clindamycin is commonly used second line due to potential resistance. Return to play guidelines are the same as for most of the bacterial dermatoses and range from 48 to 72 hours of systemic antibiotics with no moist, oozing, or exudative lesions and no new onset of lesions in the last 48 hours. First-line therapy includes acyclovir and valaciclovir, with the latter often being preferred for its twice a day dosing compared to five times daily with acyclovir. Athletes must complete oral antiviral treatment for at least 120 hours, have no new lesions for at least 72 hours, and remain free of systemic symptoms for 72 hours. Treatment is supportive and can be limited to simple rehydration for the average athlete. Diagnosis requires stool evaluation including culture, microscopy, Gram stain, and/or specific toxin testing. Once diagnosed, treatment varies depending on organism, but supportive care with electrolyte-rich hydration is always first line. Training staff may need to observe and/or teach proper handwashing technique if teams travel to endemic areas with poor hygiene. Safe practices in endemic areas include avoidance of tap water, iced drinks, or raw fruits and vegetables and only eating food served at appropriately hot temperatures. These illnesses are self-limited, but chemoprophylaxis has been used in athletes not able to miss participation; typically, ciprofloxacin 500 mg daily is used. When distinguishing between viral and bacterial upper respiratory tract infections, it is important to note that bacterial infections are less common, last longer than the usual 7- to 10-day course for a viral infection, and are associated with a history of persistent purulent rhinorrhea and facial pain. Most acute bronchitis cases are secondary to a viral etiology; less than 10% of patients have a bacterial cause. Once a gastrointestinal tract infection is diagnosed, treatment varies depending on the organism, but supportive care with electrolyte-rich hydration is always first line. The clinical management of recurrent genital herpes: current issues and future prospects. Community-acquired methicillin-resistant Staphylococcus aureus skin infection: an emerging clinical problem. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Empiric antibiotic therapy and mortality among Medicare pneumonia inpatients in 10 western states: 1993, 1995, and 1997. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. Spontaneous splenic rupture in infectious mononucleosis: sonographic diagnosis and follow-up. A clone of methicillin-resistant Staphylococcus aureus among professional football players. Outbreaks of acute gastroenteritis associated with Norwalk-like viruses in campus settings. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Prospective study of the natural history of infectious mononucleosis caused by EpsteinBarr virus. Mandatory reporting of diseases and conditions by health care professionals and laboratories. The incidence of respiratory tract infection in adults requiring hospitalization for asthma. Clinical evaluation for sinusitis: making the diagnosis by history and physical examination. Wound care accounts for approximately 10% of all procedures performed in emergency departments, with literally millions more wounds assessed yearly that do not require procedural intervention. Each wound is different, necessitating individualized treatment based on clinical assessment. Without appropriate treatment, patients with acute wounds may suffer complications such as poor healing and infections. Assuming the patient is stable and requires only management of minor wounds, assessment may progress. Careful history taking and examination are essential to appropriate assessment and treatment of wounds. Documentation should include the mechanism described by the family as well as a clear description of the wound and assessment of whether or not the wound is consistent with the mechanism described by the caregiver. Susceptible to infection because of the enclosed environment, caused by a combination of forces. A 17-year-old male patient presents with a laceration of the left hand that occurred 2 days ago. A 5-year-old male patient presents with a laceration to the scalp that is bleeding profusely. You decide it requires closure with sutures, but she refuses to allow this, stating she is afraid it will hurt. Remembering our goals of wound management, sometimes these are best served by leaving a wound to heal by secondary intent. Many wounds should not be repaired because they will heal well on their own, repair may significantly increase the risk of infection, or for other reasons. The first rule in medicine is do no harm, so repair should only be performed if necessary. Children younger than 5 years account for 18% of burns presenting to care in the United States. Of these, the majority are minor, covering <10% of the total body surface area, and the predominant type of injury is a scald. Minor superficial burns are appropriate for treatment in the acute or urgent care setting; however, those affecting larger areas, greater depths, or with other associated injuries should be referred to advanced care centers. Burns are generally classified or grouped according to three characteristics: depth of affected tissue, percent of total body surface area affected, and cause of injury (thermal, chemical, electrical, etc. These classifications are in turn used to determine the severity of a burn and aid in triage toward appropriate treatment (Table 43. Burns affecting only the epidermis are considered first degree or superficial, those affecting dermis as well as epidermis are considered second degree or partial thickness. Burns that damage or destroy all layers of skin are called third degree or full thickness. Some clinicians also consider burns damaging tissue deep to the skin as fourth degree. Burn wounds can change dramatically over the first several days after initial injury and appear more severe than on initial presentation. This occurs in spite of the burn process being arrested and is thought to be part of the pathophysiology of burns. Determining percentage of body surface area affected can be difficult, and although there are many methods utilized by clinicians to estimate this there is no perfect method. This is slightly more complex in children than in adults as various body parts comprise differing percentages of body surface area in children as compared to adults-for example, the head is proportionally much larger in children. The shape of the burn is drawn onto the chart, excluding simple erythematous areas. Each area is assigned a value of the body surface area percentage, which is entered into the table and the total body surface area affected is then calculated. A 5-year-old male patient presents to care after spilling a cup of hot tea in his lap. After exposing the affected area you note burns encompassing the anterior thighs as well as genitalia and suprapubic area. The American Burn Association sets forth criteria for burns necessitating admission as follows: 1. Burns in children at hospitals without qualified pediatric providers and facilities 10. Burns in patients who will require special supportive services or interventions 18. Irrigation of the wound with room temperature saline or sterile water is effective. The blister can act as a biodressing, but it has also been reported that devitalized tissue can serve as a nidus for infection. In this case it is acceptable to apply antibiotic ointment in place of dressing and instruct patients to wash the area a few times a day to keep the wound clean, reapplying the ointment after each cleansing. A 2-year-old male patient with no past medical conditions presents to care with burns on his chest and abdomen. He was reaching up to grab a bowl of hot soup off a table and spilled it on himself after dropping the bowl. After exposing and then cooling the burned area with sterile saline, what is the next step in appropriately treating this patient The pain associated with minor burns is often quite severe, and manipulating the wound in the process of examining and dressing the wound can make this pain worse. Intravenous intramuscular and intranasal medications should be utilized for their rapid onset and potency of pain control. Oral therapy often takes too long to take effect, limiting the practicality of its use. Local nerve blocks may also be utilized where practical to provide adequate pain control. It is also important to consider pain control after the patient is discharged home. It causes a deep puncture wound, making it difficult to irrigate, thus subjecting it to having a high infection rate. In a series done in Austria, they were able to observe a six times higher infection rate in cats (48. Amoxicillin-clavulanate 20 mg/kg (amoxicillin component) two times daily (max 875 mg amoxicillin/ 125 mg clavulanic acid per dose). How many cases of rabies have occurred in the United States after the suspected animal has been observed during the 10-day period No case of human rabies in the United States has been attributed to a dog, cat, or ferret that has remained healthy throughout the standard 10-day period of confinement after an exposure. Wildlife animals such as bats, raccoons, skunks, foxes, coyotes, and bobcats are potential sources of rabies infection for humans as well as domestic animals such as dogs, cats, and ferrets. Rabies in small rodents (squirrels, hamsters, guinea pigs) and lagomorphs (rabbits) is rare. A 10-year-old boy was playing basketball with his friends in his driveway when a neighborhood Pitbull bit him. The patient has a deformity in the right distal wrist region with an overlying 3-cm laceration and another 5-cm laceration on his left biceps region. In the United States, postexposure prophylaxis consists of a regimen of one dose of immune globulin and four doses of rabies vaccine over a 14-day period. Rabies immune globulin and the first dose of rabies vaccine should be given by the health care provider as soon as possible after exposure. Additional doses of the rabies vaccine should be given on days 3, 7, and 14 after the first vaccination. A 3-year-old girl is brought to the emergency department for evaluation of a bite mark on her arm. Caregiver reports that the bite mark is from a classmate in daycare that occurred earlier in the day. On exam, the child has an ovoid mark with teeth markings on the right radial region without a break in the skin. However, this is based on orthodontic data and has not been validated in clinical practice. Why is it recommended to obtain an x-ray on patients after a dog bite, especially bites on the extremities Dogs have large, dull teeth and powerful jaws that are capable of inducing a significant amount of damage due to a crush injury. Larger dogs are able to deliver a bite force of greater than 450 pounds per square inch, capable of perforating light sheet metal.

While Schistosoma infections can be associated with hematuria medications 5113 purchase 250mg disulfiram visa, given that she has no travel outside the United States medications you cannot crush discount disulfiram 500mg on-line, it would be highly unlikely (D) medicine 1700s order discount disulfiram online. While both metastatic and dystrophic calcification are recognized pathologic processes medications in canada cheap 500 mg disulfiram with amex, dysplastic calcification is not (E) medicine under tongue discount disulfiram 250mg with amex. Correct: Adenomyosis (B) Cervical dysplasia and neoplasia are due to infection with human papillomavirus 86 treatment ideas practical strategies disulfiram 250mg on-line. Correct: Maternal use of diethylstilbestrol (C) Clear cell adenocarcinoma of the cervix is a rare condition, strongly associated with maternal use of diethylstilbestrol during pregnancy (C). Pelvic irradiation is not commonly associated with clear cell adenocarcinoma of the cervix (E). Correct: Adenomyosis (D) Adenomyosis, which is the presence of endometrium in the myometrium, can be asymptomatic but can also cause pain, dyspareunia, abnormal bleeding, and infertility (D). Given the fact that she has three children, polycystic ovarian syndrome is less likely, and it would not normally present with pain on intercourse (B). Correct: Cesarean section just prior to onset (C) the patient has acute endometritis, which is the most common cause of a postpartum fever, frequently occurring in association with a Cesarean section (C). Cigarette smoking, congenital hypoplasia of the cervix, and endometriosis would be insignificant risk factors compared to the history of Cesarean section just prior to presentation (B, D-E). Correct: Retained placental tissue (C) the finding of endometrial glands located within the myometrium is consistent with the diagnosis of adenomyosis (B). As the endometrium is not thickened, and as both endometrial glands and stroma are present in the myometrium, endometrial carcinoma is not the diagnosis (C). Neither gestational trophoblastic disease nor endometrial stromal sarcoma fit the clinical scenario and histologic examination (D, E). A leiomyoma is composed of interlocking fascicles of smooth muscle and not glands (A). Chronic endometritis is caused by pelvic inflammatory disease, retained placental tissue, intrauterine devices, and 25. Correct: Pelvic inflammatory disease (C) the findings of fever, elevated white blood cell count, and a purulent cervical discharge are characteristic of pelvic inflammatory disease (C). While possible, squamous cell carcinoma of the cervix in a 19-year-old would be much less likely, and also, not commonly would it present acutely as an infectious process (B). Correct: Infertility (D) She has the clinical features of pelvic inflammatory disease (fever, elevated white blood cell count, and purulent cervical discharge). Due to the adhesions that can result from this condition, infertility is a complication (other complications due to adhesions include ectopic pregnancy and intestinal obstruction) (A). The condition should not cause amenorrhea, either primary or secondary (A, B), and it is not, by itself, associated with squamous cell carcinoma of the cervix (C), although both are due to a sexually transmitted disease. Uterine hypoplasia would be present from birth and would not be a major risk factor for pelvic inflammatory disease (E). Correct: Small bowel obstruction (B) the fibrous adhesions between the liver and the diaphragm is perihepatitis, i. With pelvic inflammatory disease, the patient can develop tubo-ovarian adhesions, which are a risk factor for the development of a small bowel obstruction (B). Correct: Ruptured tubo-ovarian abscess (C) the clinical findings are consistent with an acute abdomen. Given the history of a fever and purulent discharge, followed shortly by the identification of an adnexal mass, a tubo-ovarian abscess as the result of pelvic inflammatory disease is a very likely diagnosis, and, given that the patient is presenting with an acute abdomen, a ruptured tubo-ovarian abscess is most likely (C). A metastatic malignant surface epithelial carcinoma would be less likely in a younger patient, and also would be less likely to present acutely as an infectious process (D). Adenomyosis would not cause a fever, the acute abdomen, or the vaginal discharge (E). Correct: Benign prostatic hyperplasia (C) the most common reason for enlargement of the prostate, and blockage of urine flow, is benign prostatic hyperplasia (C). Given his extended period of symptoms and without an acute change in symptomatology, a strangulated hernia is unlikely (D). Although testicular lymphoma is most commonly present in older males, the clinical scenario does not otherwise support this diagnosis (E). Correct: Hydronephrosis (B) the most common reason for enlargement of the prostate and blockage of urine flow is benign prostatic hyperplasia. Common microscopic findings in benign prostatic hyperplasia include glandular proliferations; however, infarcts can occur in enlarged prostate glands, and at their periphery is squamous metaplasia (B). Neither glandular metaplasia nor ectopic Sertoli cells are commonly associated with benign prostatic hyperplasia (C, D). Correct: Osteoblastic metastatic adenocarcinoma (A) the signs, symptoms, and laboratory testing are consistent with prostatic adenocarcinoma. Prostatic adenocarcinoma commonly metastasizes to bone, and most often produces an osteoblastic response (A, B). While a sarcoma or metastatic germ cell tumor is always possible, given the clinical scenario, the most likely diagnosis is prostatic adenocarcinoma (C-F). Correct: Ectopic pregnancy (D) the clinical scenario is consistent with a patient who is bleeding. Gestational trophoblastic disease results in an enlarged uterus, and patients usually have vomiting, and can pass grape-like structures, which are the villi (C). Placenta previa usually presents later in the gestation and the patient would be having vaginal bleeding (E). Correct: Previous history of Neisseria gonorrheae infection (D) Based on the clinical scenario, the most likely diagnosis is an ectopic pregnancy, which has ruptured causing internal bleeding. Risk factors for ectopic pregnancy include a past history of Neisseria gonorrheae or Chlamydia trachomatis causing pelvic inflammatory disease, with the scarring contributing to the possibility of ectopic implantation (D). Other risk factors for ectopic pregnancy include intrauterine devices, previous abdominal surgery, and previous ectopic pregnancy. Correct: Endometriosis (B) Given that endometriosis is abnormally located endometrial tissue, including both stroma and glands, and that it can function as normal endometrial tissue. Endometriosis can form small nodules of tissue and thus cause the described physical examination findings (B). Polycystic ovarian syndrome and uterine leiomyoma would not produce such physical changes, and a uterine leiomyoma may present as a palpable mass (A, C). Metastatic breast carcinoma could cause studding of the peritoneal cavity and mimic the physical findings of endometriosis, but the symptoms would not vary with the menstrual period (D). A colloid carcinoma of the appendix can present as a pseudomyxoma peritonei, but not as described (E). The patient has the clinical features of acute prostatitis, with urinary abnormalities, lower back pain, fever and chills, and a boggy enlarged prostate on examination, which is tender to palpation (A). Prostatic adenocarcinoma and benign prostatic hyperplasia would be exceptionally rare in a young patient, and would not be tender to palpation or cause fever (C, D). The urinary tract infection by itself would not cause the changes in the prostate (E). Given his age and presentation, he most likely has an acute process, instead of a chronic process (B). Correct: Neisseria gonorrheae (C) In a young adult, acute bacterial prostatitis is uncommon. Although acute prostatitis in older males is most often due to urinary tract pathogens and often occurs in association with a urinary tract infection, in a younger male, Neisseria gonorrheae or Chlamydia trachomatis as the underlying etiology is the more common scenario (C). Correct: Presence of foreskin (C) the patient has squamous cell carcinoma of the penis. While circumcised males can develop squamous cell carcinoma of the penis, the disease most frequently occurs in noncircumcised males (C). Correct: Nodular prostate (D) the patient has the signs, symptoms, and laboratory testing consistent with a urinary tract infection, a condition that is less common in males than females. Benign prostatic hyperplasia can, by obstructing the flow of urine, predispose an individual to the development of a urinary tract infection. The other conditions listed would not be direct causes of a urinary tract infection or be indicative of a condition that is normally a cause of a urinary tract infection (A-C, E). A 43-year-old woman, during a breast selfexamination, identifies a nodule in her left breast. A 21-year-old female presents to her family physician with complaints of pain in her left breast. Physical examination reveals focal erythema of the left breast centered on the nipple. Of the following, what activity or condition most likely led to her presenting state A 45-year-old female is having her yearly examination by her gynecologist because she has noticed that her breasts have developed an ill-defined lumpy texture in a few areas when she performs a monthly breast self-examination. A subsequent biopsy reveals moderate focal epithelial hyperplasia, fibrosis, and some cysts. Compared to the normal population, of the following, what is her risk of developing carcinoma of the breast, based only on the lesion diagnosed by the pathologist A 21-year-old female presents to her ob/gyn because during a breast self-examination, she identified a mass in her left breast. A physical examination reveals a painless and mobile nodule that has a rubbery texture in the lower quadrant of her left breast. A surgical excision is scheduled, and, at surgery, the mass literally pops out of the normal breast tissue and can be removed without a rim of surrounding fat. Over the past 6 months, she has had occasionally nonmilky discharge from her left nipple; however, two days ago, she had bloody discharge. She has no history of breast cancer in her family but is still concerned by the symptoms. Physical examination reveals no masses in the left or right breast; however, compression of the left areola does express a small amount of slightly blood-tinged fluid, and a small nodule is palpable in the areola. Over the last year, she has noticed a lump in her left breast, which has grown in size. A 44-year-old female is having her yearly examination by her gynecologist because she has noticed that her breasts have developed an ill-defined lumpy texture in a few areas when she performs a monthly breast self-examination. Her mother had breast cancer diagnosed at age 56 years, and she is concerned about her chances. She does get a yearly mammogram, and this year, some linear calcification was noted. The pathologist identified ducts distended by atypical cells with necrosis in the center. Compared to the normal population, which of the following is her risk of developing carcinoma of the breast, based only on the lesion diagnosed by the pathologist Given the previous clinical scenario, based on the pathologic description of the breast lesion, of the following, what condition is this patient most directly at risk for Among only the following choices, which one is most likely to be a feature of the primary tumor in the breast The condition does not represent inflammatory carcinoma (C), an autoimmune disorder (D), or a bullous skin disease (E). The other choices are incorrect, as proliferative breast disease has an increased risk over the normal population (A, B), but it is relatively small (D, E). Correct: Fibroadenoma (B) Given the age of the patient, a neoplasm would be more rare, and neoplasms are infiltrative and would not be so easily removed without a surrounding rim of tissue (D). The patient is young for proliferative fibrocystic disease, and proliferative fibrocystic disease does not normally form well-defined masses but instead produces a lumpy breast (A). In this age group, and given the description, the most likely diagnosis is a fibroadenoma (B). Ductal carcinoma in situ, while not an invasive neoplasm, would not likely shell out from the surrounding breast tissue (C). Correct: Intraductal papilloma (E) Intraductal papillomas can cause obstruction of a duct and produce a nonmilky, sometimes bloody, nipple discharge (E). Bloody nipple discharge can also result from an invasive neoplasm, but this is a less common cause (B). A 215 16 DiseasesoftheBreast phylloides tumor is a rare neoplasm of the breast, and a leiomyoma would be a very rare neoplasm of the breast, neither likely to cause a bloody nipple discharge (C, D). As the patient presented with a metastatic lesion, the tumor has a poor prognosis. Of the choices, tumors with a high proliferative rate are associated with a poorer prognosis (E). The subtypes colloid, tubular, and medullary have a better prognosis than a typical ductal carcinoma (C). Of the choices, invasive ductal adenocarcinoma is the most common of the tumor types, and a malignant phylloides tumor and medullary carcinoma would be much less common (C, E). Central necrosis (comedo necrosis) indicates a high-grade ductal carcinoma in situ. She undergoes an emergent cesarean section and has a diagnosis of placenta previa. Following the surgery, she develops excessive thirst and frequent urination, constipation, intolerance to cold, nausea, vomiting, and increased sleepiness. A 46-year-old female presents to the emergency room because of sudden onset of a headache and double vision. Over the past few days, he has been drinking water excessively and going to the bathroom often.

Corticosteroid use for this condition should be avoided due to risk of subcutaneous atrophy and tendon damage treatment laryngomalacia infant generic 250 mg disulfiram with visa. Background: Another location of pain seen in young athletes from apophysitis is in the posterior heel treatment 1 degree burn purchase genuine disulfiram on-line. This condition is believed to result from traction of the Achilles tendon on the secondary ossification center of the calcaneus medications 2016 discount disulfiram online american express. Risk factors include high levels of athletic activity treatment 4 pink eye generic disulfiram 250 mg line, obesity symptoms electrolyte imbalance purchase cheap disulfiram on line, increased height symptoms restless leg syndrome 250mg disulfiram visa, and decreased ankle dorsiflexion. Research demonstrates the most reliable physical examination findings are positive squeeze test (lateral compression over the calcaneal tubercle) and barefoot one-leg heel standing. These have the highest sensitivity (97% and 100%, respectively) and specificity (each 100%) for making the diagnosis. Abnormalities over the calcaneus in a young athlete are neither sensitive nor specific. No radiographic sign has been found to be pathognomonic, and changes can be seen in asymptomatic, healthy individuals. For these reasons, radiographs should be reserved for ruling out pathologic abnormalities in recalcitrant cases. Ultrasound has also been investigated with some promise; however, further studies are needed. Although several treatment options are available, it does not appear they have a large impact on time to resolution, as pain improves within 3 months. Heel lifts may be recommended as those patients admitted to improved satisfaction with treatment; however, this comes with financial implications. Over-the-counter heel lifts would be desirable over custom orthotics, as their use should be short term. Do athletes with pelvic apophysitis face any risks should they continue to play in spite of pain Iliac crest apophysitis: There are many growth plates that can be affected in the pelvis; the most common is the iliac crest. Ossification of the iliac crest occurs from anterior lateral to posterior and typically takes 1 year to complete. Apophysitis of the iliac crest occurs anteriorly and more commonly affected than posteriorly due to repeat traction from the external oblique, transversus abdominis, and tensor fascia lata muscle attachments. Physical examination reveals tenderness to palpation along the iliac crest, as well as tightness of the iliotibial band, hip flexors, and rectus femoris. There is a risk for complete avulsion if the patient returns to intense activity too early. Ischial apophysitis: Another affected growth center in the pelvis is the ischial apophysis, site of hamstring insertion. Repetitive contraction of the hamstrings can cause the apophysis to become inflamed. Examination will show tenderness over the ischium and pain with straight leg raising. Conservative treatment should include partial weight bearing with use of crutches until pain free and then therapy aimed at hamstring rehabilitation. In apophysitis, the patient will complain of similar pain; however, the growth plate will remain unchanged. The lesser trochanter, which is attached to the iliopsoas tendon, can be injured from active hip extension and knee flexion. Due to the complexity of the hip anatomy, plain radiographs are important in confirming the diagnosis and ruling out avulsion. Treatment is generally conservative, including nonweight bearing, then transitioning to routine activities with therapy progression focusing on the strength and flexibility of the offended muscle. In a young athlete with lateral foot pain, does a radiolucency parallel to the shaft and across the tubercle at the base of the fifth metatarsal raise concern for fracture Background: Apophysitis of the fifth metatarsal head was first described in 1912 by Dr. The apophysis is present at the attachment of the peroneus brevis, on the plantar aspect of the base of the fifth metatarsal. Presentation: the timing of occurrence for this injury is generally between ages 10 and 12 for girls and 12 and 14 in boys. This apophysitis occurs secondary to repeat tension from the peroneus brevis or by inversion injuries. Physical examination: Physical examination will reveal tenderness to palpation at the attachment site of the peroneus brevis and pain with resisted eversion or passive extreme plantar and dorsiflexion. An enlarged tuberosity, with edema or erythema, compared to the uninvolved side, may also be appreciated. Imaging: Radiographs are not necessary to make the diagnosis; however, oblique films may visualize the ossification center and reveal a small bone piece at the plantar-lateral edge of the tuberosity or enlargement of the apophysis. The apophysis crosses the tubercle parallel to the shaft, whereas fractures occur more transverse. With a history of an acute inversion injury, radiographs should be obtained to make this differentiation. A walking boot for 1 month before progressing to physical therapy, rather than the use of crutches, could also be considered. The bony irregularity at the proximal fifth metatarsal is parallel with the shaft. This differs from a fracture to this area as the fracture will occur more transverse, across the shaft. In patients with medial epicondyle apophysitis, are there any shoulder mechanics that make them more susceptible to this injury that could be addressed and improved through physical therapy Background: Apophysitides of the upper extremity are rare due to its general lack of weight bearing. Throwers are more likely to injure their medial epicondylar apophysis (little league elbow) as the greatest amount of stress is transferred through this side of the joint. This is due to valgus extension overload and can also occur from tennis or swimming. Presentation: Patients complain of medial sided elbow pain and decreased throwing distance. For pitchers, the numbers and types of pitches thrown are important components of the history. Breaking pitches are thought to be exceptionally dangerous and should generally be avoided in the skeletally immature pitcher. Physical examination: Physical examination demonstrates tenderness to palpation over the medial epicondyle and possible bony enlargement. After athletes are pain free, they may slowly progress their throwing activities as tolerated. It is also important to address concomitant skeletal abnormalities, such as scapular dyskinesis, weak core strength, and spinal posture. These abnormalities can increase the force being transmitted through the elbow, increasing risk of injury. If the athlete is not compliant with a progression, decreasing pitch counts, and avoiding aggravating pitch mechanics, bony avulsion can occur. Olecranon apophysitis: A similar apophyseal injury can occur at the location of the olecranon from repeated triceps contraction. Patients will elicit tenderness to palpation over the olecranon and pain with resisted elbow extension. Individuals with Osgood Schlatter disease may continue to play sports in spite of pain; however, they should use pain as their guide. An athlete should discontinue activities and rest if modification of activities does not alleviate pain. Sever disease can be expected to improve within 3 months of diagnosis, regardless of therapeutic treatment. Contrary to most other areas of apophysitis, concern around the pelvis should be evaluated with radiographs to rule out avulsion fracture. If rest is not performed for little league elbow, the injury may progress to an avulsion fracture and could require surgical intervention. Factors associated with pain severity in children with calcaneal apophysitis (Sever disease). Do we really need radiographic assessment for the diagnosis of nonspecific heel pain (calcaneal apophysitis) in children A novel approach to treatment for chronic avulsion fracture of the ischial tuberosity in three adolescent athletes: a case series. Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (Sever disease). Treatment of calcaneal apophysitis: wait and see versus orthotic device versus physical therapy: a pragmatic therapeutic randomized clinical trial. Assessment of Osgood-Schlatter disease and the skeletal maturation of distal attachment of the patellar tendon in preadolescent males. A child who presents with an acute onset of limping can have a serious, sometimes life-threatening diagnosis and must have a comprehensive evaluation. Delays in diagnosis and treatment can result in significant morbidity and mortality. It is important to develop a stepwise approach to treating the acutely limping child. The differential diagnosis of limp in a child is extensive as described in Table 40. During an antalgic gait, the stance phase on the affected side will be shortened to prevent pain on that side. Assessing a limp is difficult because most children do not have a rhythmic, steady gait until after 7 years of age, so an acute change in the gait cycle that is typically observed by the parents becomes essential to help evaluate gait. What is the key factor in forming the differential diagnosis for an acutely limping child What components of the physical examination are essential when evaluating a limping child When evaluating a limping child, you must include the following in your physical examination: core and limb temperature, observed gait, knee (question of effusion), passive hip flexion with internal rotation, foot/ankle, forward bending test, abdomen, and testicles (to rule out testicular torsion). Ultrasound is highly sensitive for detecting hip effusion but is not very sensitive for differentiating among hemorrhagic, sterile, and purulent fluid accumulations. Ultrasound is also preferred when suspecting septic arthritis as it may also facilitate hip aspiration. This makes it the preferred method for diagnosing osteomyelitis and stress fractures. Patients will have a painless limp, Trendelenburg gait if unilateral, waddling gait if bilateral. They may also have leg shortening, abnormal skin creases in the leg, and limited hip abduction. Ortolani and Barlow maneuvers can be performed to aid in diagnosis and are more sensitive in infants <2 months of age. They are caused by rotational or twisting force through the tibia while on a planted foot. The most common cause of pediatric hip pain up to 10 years of age is idiopathic transient synovitis. Septic arthritis of the hip is very serious, and diagnosis should be made quickly. If the diagnosis is delayed, the patient is at risk of sepsis, growth arrest, permanent loss of joint function, and osteonecrosis. The presentation is similar to transient synovitis; however, the patient is often more toxic appearing and may have temperature elevation. Patient may hold their leg in a flexed and abducted position and have irritability with passive movement of the hip. Hip aspiration, the gold standard for diagnosing septic arthritis, should be performed whenever this diagnosis is suspected. Ultrasound is recommended over plain films because it may also facilitate aspiration. Treatment includes surgical drainage, antibiotics for a minimum of 3 weeks to cover Staphylococcus, Streptococcus, and Neisseria pathogens. Approximately 25% of patients will have long-term sequelae even after appropriate treatment with antibiotics. This disease results from interruption of the blood supply to the still-growing femoral head causing avascular necrosis. It often presents as a painless limp; if pain is present, it may be referred and present as knee or back pain. Common physical findings include leg-length discrepancies, limited abduction and internal rotation, and the presence of a Trendelenburg gait. X-rays typically reveal sclerosis of the proximal femur with joint space widening. It occurs more often in boys, with African Americans and Pacific Islanders having a higher rate of involvement, possibly due to increased levels of obesity in these population groups. The typical presentation is a limping child who may have pain in the groin, hip, thigh, or knee.

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