Professor’s Pearls
Section II: The Outpatient Office
1 Case: A mother brings her 5 year-old daughter to your office with a history of fever and a sore throat for 3 days. She could barely open her mouth because of pain. Several children in her class have had streptococcal infections. What further history would be helpful? What specific findings would you look for on physical examination, and what laboratory studies would you order to manage this patient?
2 Case: A-20-month-old is brought to your office for evaluation of limping for a few days. Her mother is concerned about her swollen right knee. The mother cannot recall seeing her toddler fall or injure that knee, despite an apparent bruise. The child has not had a fever, recent illness, or immunization. She appears stiff, and the limp is particularly noticeable when she gets out of bed in the morning. Do you want further history? What radiographs or laboratory studies would you obtain to make a diagnosis for this child?
3 Case: A 6-year-old boy presents to your office for follow-up after an emergency department (ED) visit the day before, in which he was seen for fever, nausea, and progressive swelling and redness of his right eye. At the time of the ED evaluation he had right-sided periorbital erythema and edema, full extraocular movements (EOM), and conjunctival injection. A computed tomography (CT) scan showed periorbital or preseptal cellulitis and bilateral ethmoid sinusitis. How would you manage this child?
4 Case: You have been consulted by the parents of an 11-year-old girl with poor appetite, vague abdominal pain, and fatigue for several months. The patient denies diarrhea or constipation and says the pain varies from day to day and has never been crampy. She has never had any blood in her stool. Her parents describe her as an honors student who is a perfectionist, and she has been “having difficulty handling stress.” They consulted a nutritionist who found that her caloric intake is at least 150 calories below the number expected per day. They do not have a family history of celiac disease or inflammatory bowel disease, but they do have a strong family history of constitutional short stature. She has not gained weight since her last visit 6 months ago, and her height has decreased to below the 5th percentile. On physical examination the child appears depressed and teary eyed. She has no rashes, her mucous membranes are clear, and her chest is clear to auscultation. Cardiac examination is normal with no murmurs. The abdomen is soft, flat, and nontender. Bowel sounds are normal. The perianal area is normal. Breasts and pubic hair are Tanner 1. How would you approach the diagnostic workup for this child?
Discussion by Rosemary Casey MD, Associate Professor of Pediatrics, Department of Pediatrics, Jefferson Medical College, Philadelphia, Pennsylvania.
1 Discussion: Pharyngitis is a common pediatric illness. It can be caused by a number of different viruses, as well as group A beta-hemolytic streptococcus. Further history for this patient should include the child’s oral intake, respiratory status, and whether the child can open her mouth. On physical examination, she appeared very uncomfortable, and findings included bilateral tender anterior cervical lymphadenopathy and erythematous pharynx with asymmetrically enlarged tonsils. Her left tonsil was bulging and inflamed with exudate, although her airway was patent. The rapid strep test was positive. This child could not open her mouth because of trismus. The asymmetric tonsils and trismus make a diagnosis of uncomplicated strep pharyngitis unlikely; one must consider the possibility of peritonsillar abscess. CT scan is the preferred imaging study and is helpful in distinguishing a peritonsillar abscess from a retropharyngeal abscess. CT scan confirmed the diagnosis of a peritonsillar abscess. Peritonsillar abscess requires immediate treatment because the complications include airway obstruction, septicemia, thrombosis, and rupture. She was treated with intravenous clindamycin and dexamethasone and responded quickly. Surgical drainage is sometimes necessary because of poor antibiotic penetration into the peritonsillar space.
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