Peds
Parents bring their 2-year-old child who has been ill for 1 day with irritability, vomiting, and fever. The child has a widespread maculopapular rash.
Aseptic/ Viral meningitis:
A 1-month-old girl presents to her primary care physician with a high fever that has lasted 24 hours, feeding difficulties, and irritability. Examination reveals altered mental status and a bulging fontanel.
Bacterial meningitis
The mother of a 25 month old patient is complaining that her child is irritable, bites and chews hard objects, is refusing food, had mild fever. Which of the following conditions best describes the diagnosis of the patient? A. acute tonsillitis B. Acute pharyngitis C. Normal teething D. Acute otitis
C. Normal teething
The mother of a 13 year old patient is complaining that her son has fever, malaise, loss of appetite, bad breath, odynophagia, arthralgia for the past 3 days, Physical exam denotes an alert and oriented patient, fever 102 F, hyperemic palatine tonsils and oropharynx, exudate on both palatine tonsils. Which of the following is the most likely diagnosis for this patient? A. acute bacterial pharyngo-tonsilitis B. acute viral pharyngo-tonsilitis C. oral candidiasis D. Epstein- Barr virus disease
A. acute bacterial pharyngo-tonsilitis (presence of exudate makes it bacterial)
Student presents with a 5-year history of worsening nasal congestion, sneezing, and nasal itching. Symptoms are year-round but worse during the spring season. On further questioning it is revealed that he has significant eye itching, redness, and tearing as well as palate and throat itching during the spring season. He remembers that his mother told him at some point that he used to have eczema in infancy
Allergic rhinitis Tx: steroids, antihistamines, saline, leukotriene, decongestant, ipratropium
presents with progressive hair loss at the vertex area with hair thinning at both temporal areas for the last 3 years. He is otherwise healthy and does not take any medications. On physical exam, there is diffuse hair loss over the central scalp, with frontal and bitemporal recession. There is no clinical evidence of inflammation or fibrosis. Hair-pull test is negative
Androgenetic alopecia Tx: finasteride or mindoxil
A 19-year-old man presents with a 2-day history of headache and associated nausea. He says that bright light hurts his eyes. He has no significant past medical history, is not currently taking any medication, and reports no drug allergies. He works as a librarian and has not traveled overseas for the past year. He lives with his girlfriend whom he has been seeing for 2 years. They have a pet hamster.
Aseptic/ Viral meningitis
A 12-year-old female presents with dry, itchy skin that involves the flexures in front of her elbows, behind her knees, and in front of her ankles. Her cheeks also have patches of dry, scaly skin. She has symptoms of hay fever and has recently been diagnosed with egg and milk allergy. She has a brother with asthma and an uncle and several cousins who have been diagnosed with eczema.
Atopic dermatitis Tx: emollients, steroids = desonide 0.05%/hydrocortisone 2.5% or immunomodulating: Topical calcineurin inhibitors
A 6-year-old girl with no significant past medical history presents 4 days after developing a red, irritated left eye. Her mother states that she has been wiping thick whitish-yellow discharge from her eye, and the eye is matted shut in the morning. She denies any exposure to a sick contact, upper respiratory symptoms, or contact lens use. She also denies any significant pain or light sensitivity. On examination, the patient's pupils are equal and reactive. She does not have a tender preauricular lymph node. Penlight examination does not reveal any corneal opacity, but thick, whitish discharge is seen.
Conjunctivitis Tx: erythromycin
A 4-year-old boy presents to the emergency department with complaints of dysphagia, fever, drooling, and muffled voice. Symptoms have progressively worsened over the course of the day. He is toxic-appearing, and leans forward while sitting on his mother's lap. He is drooling, and speaks with a muffled "hot potato" voice. The parents deny trauma or evidence of foreign body ingestion. They have no recollection of the child receiving a Haemophilus influenzae type B (Hib) vaccine
Epiglottis
presents with persistent, intensely pruritic, cutaneous lesions on the flexor wrists and ankles. Eruption was spontaneous and treatment with over-the-counter hydrocortisone cream and emollients were unsuccessful. On examination there are several discrete, violaceous, polygonal, flat-topped papules and plaques with overlying white reticulated scale. Onychodystrophy is also apparent. No excoriation marks are visible. Examination of the mouth reveals lacy change in the left buccal mucosa.
Lichen planus
A 9-year-old boy is brought to the ER with redness and swelling around his eye that has been present for 1 day. His left eyelid is red, tender to touch, and swollen. It will not open fully and he has a slightly decreased confrontational visual field in the left eye superiorly. He is afebrile and vital signs are normal. He denies any decrease in vision or double vision and his examination is significant for best corrected vision of 20/25 (right eye) and 20/25 (left eye). He has full motility of both eyes, has no afferent pupillary defect, and has eye pressures of 16 mmHg (right eye) and 18 mmHg (left eye). His conjunctiva and sclera are within healthy limits and the anterior chamber is deep and quiet. Fundus findings are normal in the left eye and the rest of his examination is within healthy limits. No masses are palpable. CT of orbits and sinus revealed absence of orbital fat stranding and subperiosteal abscess. Patient had opacified ethmoid and frontoethmoidal recess on the left side
Orbital cellulitis Tx: vancomycin, ceftriaxone, cefotaxmine
A 1.5 month-old infant girl is brought to her pediatrician for poor feeding. Since she was last seen at 2 weeks she has had poor weight gain. She sweats with feeds and seems to tire out easily. There is no significant family history. On PE she is noted to be tachypneic and uninterested in her bottle after a few minutes of feeding. She has increased work of breathing. On cardiac exam, she has a grade 4 continuous murmur that is heard in the left infraclavicular region and back. She also has an early diastolic rumble best heard at the apex. Her liver is 3 cm below her costal margin. Her pulses are bounding. Her CXR reveals an enlarged heart with a prominent main pulmonary artery segment and increased pulmonary markings.
Patent ductus arteriosus
presents with a 2-week history of itchy rash over her chest and back. She says it began as a single large oval lesion on her abdomen that did not improve with OTC antifungal creams, and then erupted into many smaller lesions. She recalls having felt like she had a cold the week before the first lesion arose.
Pityriasis rosea
A 6-month-old, previously well female infant presents in midwinter with a 3-day history of rhinorrhea, cough, and malaise. Several other school-age children in the home also have respiratory symptoms. The infant has a temperature of 101.2°F (38.5°C), respiratory rate of 70 breaths per minute, and oxygen saturation of 85% on room air. She has nasal flaring, head bobbing, and suprasternal and intercostal retractions. Auscultation reveals bilateral wheeze with prolonged expiration. The infant's work of breathing improves mildly with nasal suctioning, and her oxygenation improves with warm, humidified oxygen through nasal cannula, but there is no improvement with nebulized albuterol.
Respiratory syncytial virus infection
A previously healthy 9-month-old infant presents with a 4-day history of irritability and high fever in the range of 102°F to 104°F (39°C to 40°C), peaking in the early evening. On day 4 of illness his fever and irritability resolved, and he then developed a rash consisting of 2- to 5-mm red macules on his trunk that spread to his proximal extremities. The rash faded over a day and he has remained well.
Roseola (6th disease)
A 5-year-old boy who attends kindergarten presents with a 2-week history of generalized pruritus and erythematous papules in the finger web spaces, axillae, and groin. Due to his repetitive scratching, many of the lesions have secondary honey-colored crusting. No other family members are affected.
Scabies
A 14-year-old boy presents with a 1-day history of fever, photophobia, chills, cough, tonsillar enlargement, and chapped, bleeding lips. He has a diffuse erythematous rash including the palms and soles of his feet, in total covering 57% TBSA. Within 24 hours the rash progresses to 87% TBSA involvement and the patient requires mechanical ventilation for respiratory distress. He has a history of asthma and has been taking ibuprofen for an upper respiratory infection that developed 2 weeks previously.
Steven- Johnson- Syndrome
A 15-year-old boy presents with a month-long history of itching and scaling in the groin region. Physical exam reveals hyperpigmentation of skin on both upper medial thighs and inguinal areas with scaling and secondary excoriation. There is sparing of the scrotum and penis; also noted is some maceration between the fourth and fifth toe of his right foot that causes burning and itching. He competes as a member of his high school swim team.
Tinea
A 3-year-old boy presents with a 3-week history of a circular scalp area of hair loss and flaky skin. He attends daycare and is provided a sleep mat for an afternoon nap, which is not exclusively for his use. The scalp lesion is not itchy, but has not gone away with an antidandruff shampoo. There are no other skin lesions present.
Tinea
A 13-year-old girl is brought to a pediatrician by her mother, who is concerned about short stature and the lack of any signs of pubertal development. Her 11-year-old sister is 10 cm taller and has already had breast development. Parents are average in height with puberty at the age of 12 or 13 years. Past medical history is only significant for frequent otitis media. Physical exam reveals a short girl of 135 cm (<1st percentile), weight of 55 kg with mild hypertension (130/80 mm Hg), and a pubertal stage of Tanner I for breast and Tanner II for pubic hair development. The remainder of the exam is normal apart from multiple melanocytic nevi on the face and arms, as well as a high-arched palate. A bone age x-ray of the wrist was consistent with an age of 11.5 years.
Turner's syndrome:
A 7-year-old healthy girl presents with a rough bump on the lateral side of the right second finger that has been enlarging over the past 4 months. It has become fissured, bleeds when scratched, and becomes tender after manipulation. Physical examination reveals a fissured, grayish-white, raised hyperkeratotic papule with a rough surface. Gentle paring of the lesion reveals tiny black dots.
Verrucae (etiology: HPV)
A 6-year-old girl is brought to her pediatrician for routine well-child care. She is doing well and has never experienced chest pain, palpitations, or syncope. She actively participates in a dance class and reports being able to keep up with her peers. There is no family history of congenital heart defects. She is well-appearing with no apparent distress. Her left ventricular impulse is normal, and there is a subtle right ventricular lift. Her second heart sound is widely split and does not vary with respiration. She has a soft 1-2/6 systolic ejection murmur best heard along the left upper sternal border. The remainder of her physical exam is normal.
atrial septal defect
A 3-year-old boy is brought to the emergency room by his parents in the late evening. He has developed a sudden onset of a seal-like barky cough, accompanied by clear nasal discharge. His parents became alarmed when he developed stridor, which persists throughout the trip to the hospital. On examination, he has a seal-like barky cough and inspiratory stridor when at rest, which worsens with agitation. Persistent sternal indrawing is also evident at rest.
croup
An infant is noted at birth to have a cardiac murmur. Physical exam reveals a systolic murmur at the left sternal border. There is no clinical evidence of heart failure.
ventricular septal defect
An infant presents with symptoms of shortness of breath on exertion, and failure to thrive. Physical exam reveals a systolic murmur at the left sternal border and signs of congestive heart failure.
ventricular septal defect
A 5-year-old girl presents to the emergency department with a 2-day history of coryza and cough with intermittent low-grade fever. She developed an audible wheeze and respiratory distress that was initially responsive to albuterol via a pressurized metered-dose inhaler and small-volume spacer. However, symptoms have recurred within 2 hours of albuterol administration. The patient has had a number of episodes of wheeze and dyspnea over a 2-year period; these were more common during the winter months. She required prednisone on 2 occasions to treat severe wheeze. On exam, she is in visible respiratory distress with a respiratory rate of 40 breaths/minute and has accompanying accessory muscle use. Her oxygen saturations are 92% in room air, and on auscultation of her chest there is widespread polyphonic wheeze and equal air entry. She has an audible moist cough
Acute asthma exacerbation
An 18-month-old toddler presents with 1 week of rhinorrhea, cough, and congestion. Her parents report she is irritable, sleeping restlessly, and not eating well. Overnight she developed a fever. She attends day care and both parents smoke. On examination signs are found consistent with a viral respiratory infection including rhinorrhea and congestion. The toddler appears irritable and apprehensive and has a fever. Otoscopy reveals a bulging, erythematous tympanic membrane and absent landmarks
Acute otitis media (etiology: strep pneumon/ non type H.influenza/ Moraxella) Tx: Augmentin if allergic to PNC: ceftriaxone or Azithromycin
A 7-year-old girl presents with abrupt onset of fever, nausea, vomiting, and sore throat. The child denies cough, rhinorrhea, or nasal congestion. On physical exam, oral temperature is 101°F (38.5°C) and there is an exudative pharyngitis with enlarged, tender anterior cervical lymph nodes. A rapid antigen test is positive for group A Streptococcus (GAS).
Acute pharyngitis
A 7-year-old girl presents with acute sore throat accompanied by fever. On exam, oral temperature is 98.6°F (37°C) and there is an exudative pharyngitis without palpable cervical nodes. Both the rapid antigen test and throat culture are negative for group A Streptococcus (GAS).
Acute pharyngitis
An 18-year-old male student presents with severe headache and fever that he has had for 3 days. Examination reveals fever, photophobia, and neck stiffness.
Bacterial meningitis
The mother of a 6 year old patient is complaining that her son has fever (40C), drooling, loss of appetite, dysphagia everything started 3 hours ago. Physical exam denotes a patient with toxic appearance on a tripod posture, dyspnea, stridor, and muffled voice. Which of the following is the most accurate diagnosis for this patient? A. epiglottitis B. Retropharyngeal abscesses C. Uvulitis D. Pharyngo-tonsillitis
A. epiglottitis
A 6-year-old female without significant past medical history presents for evaluation of frequent unusual episodes for the past 3 months. The unusual episodes consist of sudden activity arrest with staring and minimal eyelid flutter for 10 to 20 seconds occurring 5 to 10 times per day. The patient is unresponsive to voice or tactile stimulation during the episodes. She is able to immediately resume activities without any recollection of the event once the episode finishes. Her teachers have noted that she stares off in class repeatedly and does not seem to be remembering instructions and classroom material. The diagnosis of attention-deficit/hyperactivity disorder had been suggested. One such unusual episode is induced in front of medical staff with hyperventilation.
Absence seizures
A 10-week-old boy presents to his physician's office in January because his mother feels his breathing is labored. He was a full-term product of an uncomplicated pregnancy, labor, and delivery. His mother smoked during pregnancy and continues to do so. The family history is negative for asthma or allergy. He developed rhinitis and a tactile fever 3 days prior to presentation. Over the next few days he developed increasing cough, increased work of breathing, and decreased oral intake. On examination, his temperature is 100.4°F (38.0°C), his respiratory rate is 42 breaths per minute, and his oxyhemoglobin saturation, measured by pulse oximetry, is 93% while breathing room air. He has a wet cough. His chest exam reveals mild intercostal retractions, scattered crackles bilaterally, and expiratory wheezes bilaterally.
Bronchiolitis (etiology: RSV; Tx: oxygenate & hydrate)
A 20-month-old toddler was playing in the living room while her father was preparing dinner. She ran into the kitchen and bumped into her father's legs as he was carrying a pot of boiled pasta to the sink to empty the hot water. He tripped and spilled the boiling pasta and water onto the child's head, face, and upper body. Physical exam reveals blistering sloughing skin with underlying wet, tender erythema
Burns
The mother of an 3 month old patient is complaining that her son has problems swallowing and constantly vomiting after she breast fed him, she noticed that her son has creamy white plaques on his mouth 2 days ago. Physical exam denotes a patient irritable, with normal vital signs, oral cavity with multiple slightly raised lesions with a cottage cheese-like appearance on the gums tongue and inner cheeks. Which of the following is the most likely diagnosis for this patient? A. oral cryptosporidiosis B. oral aspergillosis C. oral candidiasis D. oral cryptococcosis
C. oral candidiasis Tx: nystatin suspension
A 4-year-old boy presents to his pediatrician for a well-child visit. His mother reports him to be doing well and has no concerns. On exam, he is noted to have a right upper extremity BP of 140/70 mmHg. His cardiovascular exam shows a quiet precordium, a normal point of maximal impact, normal S1, and normally split S2. A 2/6 long systolic murmur is heard over his back, and 2+ radial pulses and trace femoral pulses are felt.
Coarctation of the aorta
A newborn infant is noted to have respiratory distress 2 days after birth. On examination she is mottled and has weak upper extremity pulses with no palpable femoral pulses. Her ABG shows a profound metabolic acidosis.
Coarctation of the aorta
A 14-year-old boy with no significant past medical history presents 3 days after developing a red, irritated right eye that spread to the left eye today. He has watery discharge from both eyes and they are stuck shut in the morning. He reports recent upper respiratory symptoms and that several children at his day camp recently had pink eye. He denies significant pain or light sensitivity and does not wear contact lenses. On examination, his pupils are equal and reactive and he has a right-sided, tender preauricular lymph node. Penlight examination does not reveal any corneal opacity
Conjunctivitis
A 16-year-old girl presents with a progressively worsening pruritic eruption in the periumbilical region. She reports wearing blue jeans with metal buttons and a belt with a metal buckle on an almost daily basis. She previously developed pruritic eruptions around the neck and earlobes when wearing costume jewelry. Physical exam reveals erythematous to hyperpigmented periumbilical papules and plaques with sharp demarcation, and hyperpigmented patches on the neckline and ear lobes.
Contact dermatitis Tx: triamcinolone 0.1% or clobetasol 0.05% topical if more than 20% of skin involved systemic steroids.
The mother of an 8 year old patient is complaining that her son is getting bad grades at school because her son's school teacher says that he is always staring at the window, with an accelerated blinking of the eyes and lip smacking. During these episodes the child does not follow commands to desist his action and to pay attention in class. Which of the following is the most likely clinical diagnosis for this patient? A. Atonic seizures B. Focal seizures without loss of consciousness C. Tonic seizures D. Absence seizures
D. Absence seizures (key word: lip smacking)
The mother of a 4 year old patient is complaining that her son has malaise, fever (103 degrees F), loss of appetite for the last 2 days and today he started having sidden brief jerks or twitches of his arms and legs that lasted 2 minutes. Which of the following condition best describes the etiology causing these movements? A. Grand mal epilepsy B. Petit mal epilepsy C. Cerebra vascular disease D. Febrile seizure
D. Febrile seizure
The mother a 3 month old patient is complaining that her daughter is having fever, vomiting, irritable, unable to eat and lethargic all these abnormalities started 1 day ago. Physical exam reveals: bulging anterior fontanelles, evidence of dehydration, and petechial rash. Which of the following is the most likely clinical diagnosis for this patient? A. Meningitis by E.Coli B. Meningitis by Enterobacterias C. Meningitis by Group B streptococci D. Meningitis by Neisseria meningitides
D. Meningitis by Neisseria meningitides (petechial rash makes you go towards Neisseria)
An 8-month-old girl presents with mild erythema of the labia majora, perianal area, and convex surfaces of buttocks for the past 2 days following a 3-day history of diarrhea.
Diaper dermatitis Tx: topical barriers such as vaseline, zinc oxide, sulcralfate; powders; antifungal; steroids
A girl is born at term after a normal pregnancy and delivery. On examination she is noted to be hypotonic with hyperextensible joints, small ears, and a small mouth. She has a protruding tongue, a broad neck, an upward slant to the eyes with epicanthal folds, and a single palmar crease.
Down syndrome
The result of an amniocentesis in a pregnant 39-year-old mother reveals a chromosomal karyotype of 47,XX,+21.
Down syndrome
A 7-year-old girl presents with frequent nosebleeds, worse on the left. There is no active bleeding on presentation. Her mother reports previous treatment with office cautery using silver nitrate. She has concerns about the cautery being repeated as it was painful for the child. Examination shows small blood vessels in the most anterior septal mucosa, bilaterally.
Epistaxis M/C: nose picking = trauma Tx: with nasal packing or cautery
A 10-month-old girl is brought to the emergency department with a history of recurrent right arm and leg jerking followed by prolonged sleepiness. The parents report a 2-day history of fever with chest congestion and irritability. The child is admitted to the hospital for neurologic evaluation.
Febrile seizures
An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upward through her chest. She is usually unaware for a few minutes, but others have told her that she smacks her lips, picks at her clothing, and is unable to speak during these episodes. After the event, she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her past medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.
Focal seizures
A 10-year-old girl presents after having had a generalized tonic-clonic seizure while at school the previous day. It lasted approximately 2 minutes and she was incontinent of urine during the episode. Afterward she complained of headache and feeling tired. She had been well prior to this episode and there is no family history of epilepsy. General physical exam and neurologic exam on the day after the seizure are normal.
Generalized seizures
A 15-year-old boy presents with a history of having had 2 seizures. He is healthy and has no relevant past medical history. There is no family history of epilepsy. Both episodes happened early in the morning and were self-limited. The jerking of the whole body and limbs lasted <5 minutes, and he was sleepy for a number of hours after the episodes. General physical and neurologic exams are normal.
Generalized seizures
A 21-year-old active college student with no past medical history has sudden loss of consciousness, 1 hour into a game of basketball. CPR is administered by bystanders. On arrival of emergency medical professional, he has regained consciousness. The family history is significant for a murmur in his father and grandmother only. Physical examination reveals a systolic ejection murmur that increases in intensity when going from a supine to a standing position and disappears with squatting.
HCM
A 5-day-old newborn presents with a rapidly enlarging bulla with thin roof and a thin band of erythema around the bulla. The bulla is flaccid and contains clear fluid. Careful examination reveals an adjacent smaller bulla. The baby is well.
Impetigo (etiology: bullous: staph aureus) Tx: dicloxacillin
A 5-year-old boy presents with superficial erosions and crust in the perioral region for 3 days. He is generally well with no recent history of fever, sore throat, nausea, diarrhea, or changes in appetite or energy level. There is a history of similar eruption in other children at his nursery.
Impetigo (etiology: non-bullous: staph aureus/GAS) Tx: dicloxacillin
An 8-year-old white girl presents to be checked for lice because her mother is concerned she may have another infestation. She has treated her daughter with over-the-counter pediculicide 3 times in the past 2 months, but admits she is not sure what to look for - she treats when she hears about a case in her daughter's class. When examining her scalp under a bright light, dozens of small white objects firmly adherent to the hair shaft can be seen, but all are more than 1 cm from the scalp. Microscopic examination of one shows it to be an empty louse egg case, indicating the girl most likely had an infestation 2 months ago that resolved
Lice
A 7-year-old white girl presents to the school nurse. She was referred by her teacher, who noted she was scratching her head a lot. The school nurse knows there have been no active cases of head lice identified in this student's class recently, but the girl says she had been to a "sleepover" about 1 month ago. The girl has shoulder-length hair, and claims she has never had head lice before. When the school nurse examines the nape of the girl's neck, she finds small whitish spots within 1 cm of the scalp that are firmly adhered to the hair shaft. As the nurse continues to examine the girl's scalp under bright light, she sees a sesame seed-sized insect-like object crawl quickly away from the area
Lice Tx: permethrin topical and ivermectin oral
A 28 week premature boy is treated with appropriate doses of surfactant. However, on his second day of life he has worsening symptoms of respiratory distress syndrome with increasing ventilatory requirements. He has also started demonstrating apneic episodes. He is noted to have a widened pulse pressure (30 mmHg) on his arterial line and he is starting to have some bloody stools. On PE, he is noted to have bounding pulses and a prominent precordial impulse. On auscultation a grade 3 systolic ejection murmur can be heard in the left infraclavicular area. His abdomen also appears distended. On CXR, his lungs fields are almost completely opacified.
Patent ductus arteriosus
A 4-month-old healthy girl with normal prenatal and birth history is brought in by her parents, who note that both her eyes are looking toward the nose. Exam shows a large-angle esotropia with freely alternating fixation (i.e., each eye fixates objects, with no preference for either eye). No significant refractive error is present, and the remainder of the eye exam is normal. The infant is diagnosed with infantile esotropia
Strabismus
A 1-day-old infant in the general care nursery born at full term by uncomplicated spontaneous vaginal delivery is noted to have a murmur on exam. The baby otherwise appears well. On exam, respiratory rate is 40 and pulse oximetry is 96%. Precordium is normoactive. With auscultation, S1 is normal, S2 is single, and a 2/6 systolic ejection murmur is heard at the left upper sternal border.
Tetralogy of Fallot
A 1-day-old infant in the general care nursery born at full term by uncomplicated spontaneous vaginal delivery is noted to have cyanosis of the oral mucosa. The baby otherwise appears comfortable. On exam, respiratory rate is 40 and pulse oximetry is 80%. A right ventricular lift is palpated, S1 is normal, S2 is single, and a harsh 3/6 systolic ejection murmur is heard at the left upper sternal border.
Tetralogy of Fallot
A 10-year-old female Pacific Islander presents with a 2-day history of fever and sore joints. Further questioning reveals that she had a sore throat 3 weeks ago but did not seek any medical help at this time. Her current illness began with fever and a sore and swollen right knee that was very painful. The following day her knee improved but her left elbow became sore and swollen. While in the waiting room her left knee is now also becoming sore and swollen.
acute rheumatic fever
An 8-year-old boy presents with intermittent wheeze and cough, and with a history of asthma. Over recent months he has had problems with nighttime wheeze and shortness of breath. He is waking at least 3 or 4 nights per week since recovering from an upper respiratory infection. He requires his beta-2 agonist metered dose inhaler (MDI) to enable him to get back to sleep. He has also noted more problems with wheeze and shortness of breath on minimal playing at school. His general practitioner has tried cromolyn sodium and a leukotriene receptor antagonist in the past, but currently he is managed with beta-2 agonist as required. He now needs a new beta-2 agonist MDI every 2 to 3 weeks.
asthma
A 2-year-old boy is brought to the emergency room by his parents in the middle of the night. He has had mild symptoms of an upper respiratory infection for 48 hours, awoke with a sudden onset of seal-like barky cough and has had inspiratory stridor when crying. The stridor disappeared at rest, but the seal-like barky cough has persisted.
croup (etiology: Parainfluenza virus type 1 )
A 1-year-old child presents with failure to thrive. By history, the child was born at the 50th percentile for weight, but has crossed multiple percentile lines despite having a ravenous appetite. The child has more bowel movements per day than other children of the same age, and the stools often look shiny and have an unusually foul smell. In addition, the child has been treated with multiple courses of antibiotics for a persistent, wet cough. On measurement, the child is small for age, with weight and length below the third percentile.
cystic fibrosis
A previously healthy and developmentally normal 18-month-old boy presents to the emergency department by ambulance after his parents witnessed a seizure. The parents report the boy had a febrile illness with mild upper respiratory symptoms and they treated him with acetaminophen and ibuprofen at home. The child then began to have frequent jerking movements of all limbs. The rectal temperature was 103.1°F (39.5°C). The parents called 911, and an acetaminophen suppository was administered during transport to the emergency department. The jerking stopped after approximately 5 minutes. Afterward, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurologic status.
febrile seizure
A 3-year-old boy was playing with colorful interlocking plastic bricks when he suddenly started coughing and gagging. The child subsequently developed a high-pitched sound and his breathing became labored. The child's caregiver called the paramedics, but while waiting for the ambulance the child's breathing slowed and he became unconscious.
foreign body
A previously healthy 1-year-old female was admitted to a children's hospital with a 7-day history of spiking fever up to 103°F (39.5°C). Three days after the onset of fever she developed left-sided neck swelling and diaper rash, and became progressively fussy and irritable. She was seen at an emergency room, diagnosed with cervical adenitis, and sent home on oral antibiotics. The mother noted continued irritability, high fever, and decreased oral intake. On subsequent admission she was extremely irritable, with a temperature of 102°F (38.9°C), heart rate of 140 beats per minute, respiratory rate of 40 breaths per minute, and blood pressure 110/54 mmHg. There were no signs of nuchal rigidity. Both palpebral and bulbar conjunctivae were deep red and injected, lips were dry and crusted, the oropharynx hyperemic with some areas of ulcerated mucosa, and the tongue papillae were enlarged and red (strawberry appearance). Examination of the neck revealed a mildly tender left unilateral mass, measuring 4 cm. The skin showed a generalized polymorphous, erythematous, macular, blanching rash, in addition to severely red and desquamated perineal region. Her extremities, especially palms and soles, were swollen, red, and mildly tender.
kawasaki's disease
presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient complains of otorrhea and mild decreased hearing. He reports that his symptoms started after swimming. No fever is reported. On physical exam the external ear canal is diffusely swollen and erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was partially visualized due to the swelling. The concha and the pinna look normal. Neck exam fails to reveal any lymphadenopathy.
otitis externa (etiology: staph aureus) Tx: Ciprodex otic drops empirical oral: dicloxacillin
