[ { "article_id": 190, "article_title": "Inhalation Injury", "sections": [ { "title": "Management at the bedside", "content": "**Initial assessment (ABC approach)**\n\n1. **Airway evaluation first** — Inhalation of hot gas causes rapid local oedema and loss of airway patency. The threshold for intubation is lowered in children because small airway diameter makes them vulnerable to rapid compromise.\n\n2. **Concomitant poisoning is recognised** — Carbon monoxide and cyanide exposure are screened for, as these contribute significantly to morbidity and early death.\n\n3. **Arterial blood gas is obtained** — Carboxyhemoglobin level is measured. Pulse oximetry is not relied upon, as oxygen saturation values are often falsely elevated.\n\n**Mild inhalational injury**\n\n- Supplemental oxygen\n- Albuterol nebuliser treatment if wheezing is present\n- Racemic epinephrine nebuliser treatment if stridor is present\n- Close monitoring for deterioration\n- Steroids are generally not recommended\n\n**Significant inhalational injury**\n\n- **Early intubation** — Performed promptly if there is any evidence of airway burns or oedema, or if [[151|respiratory distress]] develops\n- **Mechanical ventilation** — Positive end-expiratory pressure is used to reduce pulmonary oedema from vascular leak\n- **Inhaled anticoagulant** — Considered within 2–4 hours of injury (e.g. tissue plasminogen activator or heparin) to prevent obstructive fibrin formation\n- **Non-invasive ventilation** — Continuous positive airway pressure devices may benefit awake, cooperative patients with lesser pulmonary involvement and few facial burns\n- **Fluid management** — Careful attention to fluid balance\n- **Antibiotics** — As needed for superinfection\n\n**Serial endoscopy**\n\nIf clinical assessment is uncertain, an experienced physician performs serial endoscopy to visualise laryngeal soft-tissue changes. If oedema is present, the airway is splinted open by intubation.\n\n**Admission criteria**\n\nAdmission to intensive care occurs if unstable airway, respiratory distress, severe hypoxia, ongoing blood loss, or other severe injuries are present." } ] }, { "article_id": 191, "article_title": "Lyme Disease", "sections": [ { "title": "Management of Early Lyme Disease", "content": "**Diagnosis:** Early localized Lyme disease is diagnosed clinically based on the characteristic erythema migrans lesion in an endemic area.\n\n**Treatment:** Early Lyme disease should be treated orally for 14 days.\n\n**Antibiotic selection by age:**\n\n- **Children 8 years and older:** Doxycycline is recommended. Unlike amoxicillin, doxycycline also treats patients with concurrent anaplasmosis.\n- **Children younger than 8 years:** Amoxicillin is recommended.\n- **Penicillin-allergic patients:** Cefuroxime is the alternative drug.\n- **Note:** Erythromycin and azithromycin are less effective.\n\n**Co-infections:** Patients with Lyme disease who are simultaneously infected with *Babesia microti* (babesiosis), *Anaplasma phagocytophilum* (human granulocytic anaplasmosis), or both should be treated for each infection.\n\n**Reassurance:** If a patient reports having had a tick on them for only a few hours the previous day, provide reassurance that no treatment is necessary." } ] }, { "article_id": 192, "article_title": "Pediatric Oncology", "sections": [ { "title": "Clinical Approach", "content": "**Initial Assessment**\n\nWhen evaluating a pediatric oncology patient presenting to clinical care:\n\n1. **History taking** — The patient's and parents' perspective on the cause of symptoms and current clinical status is explored. A detailed medication history is obtained, documenting all current medications (chemotherapy agents, antibiotics, antiemetics, and supportive care medications) and their timing, as side effects may contribute to presenting symptoms.\n\n2. **Differential diagnosis** — Malignant processes are included in the differential diagnosis of common childhood complaints. Oncologic emergencies require prompt identification.\n\n3. **Psychosocial context** — The extreme stress a cancer diagnosis places on families is acknowledged, and care is provided with appropriate compassion and professionalism.\n\n**Ongoing Management**\n\nLong-term follow-up care of pediatric cancer survivors should incorporate:\n\n- Exposure-based health screening guidelines to provide a framework for high-quality supervision\n- Ongoing dialogue with pediatric oncology subspecialists regarding changes in follow-up recommendations\n- Monitoring for late effects including hematologic, infectious, neurologic, cardiovascular, hepatic, and gastrointestinal complications\n- Pain and symptom control throughout treatment and in terminal care" } ] }, { "article_id": 193, "article_title": "Acute Abdomen", "sections": [ { "title": "Bedside Management", "content": "**Initial Assessment**\n\n1. **History**: The pain is characterised (onset, duration, location, progression), along with associated symptoms (vomiting—bilious or nonbilious, diarrhoea, fever), recent exposures (sick contacts, travel), and relevant past medical history.\n\n2. **Physical Examination**:\n - General appearance and toxicity are assessed\n - The abdomen is palpated using flat surface of fingers (not fingertips)\n - Guarding, distension, and tenderness (location and severity) are evaluated\n - Bowel sounds are auscultated\n - The right lower quadrant is examined specifically (McBurney's point)\n - Skin is inspected for petechiae or purpura\n - Signs of [[99|dehydration]] or [[226|sepsis]] are assessed for\n\n3. **Initial Investigations**:\n - Full blood count\n - C-reactive protein level\n - Plain vertical abdominal X-ray\n - Abdominal ultrasonography\n\n**Management Strategy**\n\n**For patients appearing toxic or with findings concerning for surgical abdomen** (bilious vomiting, guarding, significant tenderness, absent bowel sounds):\n- Nothing is given by mouth\n- Intravenous access is established\n- Urgent surgical consultation is obtained\n- Antibiotics are deferred pending surgical evaluation\n\n**For nontoxic patients with atypical presentations**:\n- Nothing is given by mouth\n- Antibiotics are deferred until diagnosis is more certain\n- Serial abdominal examinations are conducted\n- Laboratory studies (full blood count, C-reactive protein) are repeated as dictated by clinical suspicion\n- Early surgical consultation is arranged if clinical concern persists\n\n**Key Principle**: A low threshold for early surgical consultation is maintained, particularly in infants and young children where diagnostic difficulty is greatest and rapid progression of pathology can occur." } ] }, { "article_id": 194, "article_title": "Acute Rheumatic Fever", "sections": [ { "title": "Management", "content": "**Initial Assessment**\n\n- Detailed history of preceding pharyngitis is obtained (even if not recalled by patient or family)\n- Thorough cardiac examination is performed, auscultating for systolic murmur at apex (mitral regurgitation) or early diastolic murmur (aortic regurgitation)\n- Other manifestations are assessed for: migratory joint pain/swelling, subcutaneous nodules, erythema marginatum, neurological signs (chorea)\n\n**Investigations**\n\n- Inflammatory markers are measured: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)\n- Antistreptolysin O (ASO) and anti-DNase B titers are obtained\n- 12-lead electrocardiogram is performed to assess for heart block\n- Chest radiograph is obtained to evaluate for cardiomegaly, pulmonary edema, or pericardial effusion\n- **Echocardiography is arranged at a qualified center** in all suspected cases to assess for carditis, valvular regurgitation, myocardial dysfunction, and pericardial effusion\n\n**Cardiac Evaluation**\n\nAll patients require thorough cardiac evaluation and echocardiography. Approximately 5–10% of patients develop severe [[100|myocarditis]] with heart failure requiring aggressive treatment.\n\n**Secondary Prevention**\n\nFor patients with confirmed ARF, long-term chemoprophylaxis is initiated:\n\n| Drug | Dose | Route | Frequency |\n|------|------|-------|----------|\n| Penicillin G benzathine | 1.2 million units | Intramuscular | Every 4 weeks |\n| Penicillin G benzathine | 600,000 units | Intramuscular | Every 4 weeks (for lower body weight) |\n\n**Primary Prevention**\n\nPrompt diagnosis and treatment of acute GAS pharyngitis in the emergency department is the most effective means of preventing rheumatic heart disease and ARF development." } ] }, { "article_id": 195, "article_title": "Atopic Dermatitis", "sections": [ { "title": "Management", "content": "### Skin Care Foundation\n\nBasic skin care measures are used for all patients:\n- Irritants and proven allergens are avoided\n- Skin hydration is maintained with regular moisturizers of good quality\n- Skin is wetted for 5–10 minutes twice daily\n\n### Topical Corticosteroids (First-Line)\n\nTopical corticosteroids are used as first-line therapy in patients requiring more than moisturizer alone.\n\n**Low potency:**\n- Hydrocortisone 1%, 2.5%\n- Desonide 0.05%\n\n**Moderate potency:**\n- Hydrocortisone valerate 0.2%\n- Mometasone furoate 0.1%\n- Triamcinolone 0.1%\n- Fluocinolone 0.1%\n\n### Topical Calcineurin Inhibitors (Second-Line)\n\nTacrolimus is approved for patients 2 years of age or older as second-line treatment.\n\n### Systemic Therapy\n\nFor severe disease:\n- Cyclosporine\n- Ultraviolet therapy\n\n### Infection Management\n\n**Bacterial superinfection:** Oral antibiotics are required when superinfection occurs but are not indicated for routine prophylactic use.\n\n**Herpes simplex/[[288|eczema]] herpeticum:** Acyclovir treatment is initiated. If periorbital skin or nasal tip involvement is present, ophthalmologic consultation is obtained. Severe cases may require hospitalization for intravenous antiviral therapy.\n\n**Candida coinfection:** Topical nystatin, clotrimazole, or miconazole is used.\n\n**Tinea corporis:** Treated with topical antifungal agents.\n\n**[[339|Tinea capitis]]:** Requires systemic antifungal therapy.\n\n**Malassezia-related scaling:** Antifungal shampoos may help reduce scaling.\n\n### Antihistamines\n\nSedating antihistamines help most with itching. Note that topical calcineurin inhibitors can cause stinging and burning sensations on application.\n\n### Patient and Family Education\n\nFamilies are informed that there is no immediate cure; treatment aims to control the disease. Weeks of effective control may be followed by sudden severe relapse. Careful attention to aggravating factors (dry skin, sweating, stress, secondary infection) is essential." } ] }, { "article_id": 196, "article_title": "Atrioventricular Septal Defect", "sections": [ { "title": "Management", "content": "**Initial Assessment**\n\n1. Clinical context is identified: newborn with Down syndrome or signs of heart failure (poor feeding, tachypnoea, hepatomegaly) at 2–3 weeks of life\n2. Physical examination is performed: loud pulmonary component of S2 is assessed for; murmur may be absent in neonates\n3. 12-lead ECG is obtained: extreme left axis deviation and superior axis are sought\n\n**Diagnostic Confirmation**\n\n4. Urgent echocardiography (gold standard) is arranged:\n - Apical four-chamber view to visualize common atrioventricular valve spanning atrial and ventricular defects\n - Colour Doppler to assess regurgitation jets and left-to-right shunting\n - Chamber sizes are measured and right atrial enlargement is assessed\n5. Chest radiograph is obtained to assess for cardiomegaly, pulmonary vascularity, and venous congestion\n\n**Medical Management (Acute Phase)**\n\n6. Heart failure is treated:\n - Fluid intake is restricted\n - Diuretics are administered as needed\n - Nutrition is optimized and growth is monitored\n7. Complications, including pulmonary [[92|hypertension]], are monitored for\n\n**Definitive Treatment**\n\n8. Referral for surgical repair is made at 3–6 months of age\n - Procedure involves separating the common valve into mitral and tricuspid components\n - Closure of atrial and ventricular septal defects" } ] }, { "article_id": 197, "article_title": "Breastfeeding Difficulty", "sections": [ { "title": "Management", "content": "**Assessment and Initial Evaluation**\n\n1. **The source of difficulty is determined** through history and observation:\n - Maternal: nipple pain, engorgement, inadequate milk supply, or systemic illness\n - Infant: poor latch, ankyloglossia, nasal congestion, or systemic illness\n\n2. **The infant is evaluated for illness** if presenting with decreased feeding interest accompanied by lethargy, fever, vomiting, diarrhea, cough, or difficulty breathing—referral to pediatrician is made\n\n3. **Latch and positioning are assessed** to identify poor technique as cause of nipple pain or inadequate milk transfer\n\n**Management of Specific Problems**\n\n**Nipple pain and trauma:**\n- Positioning and latch technique are corrected\n- Nipple wounds are lubricated and covered to promote healing\n- Breastfeeding continues with corrected latch\n- Referral to certified lactation consultant is made if severe or persistent\n- Pain medication safe during breastfeeding may be offered if needed\n\n**Engorgement:**\n- Feeding frequency is increased\n- Manual pumping or expression is performed before feedings to soften breast and improve latch\n\n**Infant nasal congestion:**\n- Nasal passages are cleared with bulb syringe prior to feeding\n\n**Feeding frequency and duration:**\n- At least 8–12 feedings per day are recommended when infant shows early feeding cues\n- Approximately 10–45 minutes per feeding is targeted\n- 1 hour per feeding is not exceeded\n- Adequate infant intake is prioritized over feeding duration\n\n**Referral and Support**\n\n- Referral to certified lactation consultant is made for severe nipple pain, suspected latch problems, or inadequate milk transfer\n- Referral to pediatrician is made for infant illness, suspected ankyloglossia, or [[104|failure to thrive]]\n- The mother is connected with family support, peer support networks, and reliable breastfeeding information resources\n- For mothers with opioid use disorder, trauma-informed counseling and support are provided" } ] }, { "article_id": 198, "article_title": "Bronchopulmonary Dysplasia", "sections": [ { "title": "Management Approach", "content": "**Initial Assessment and Monitoring**\n\nRisk is identified in premature infants on mechanical ventilation or supplemental oxygen beyond 10–14 days. Severity is assessed at 36 weeks postmenstrual age (or 56 days of age in infants >32 weeks' gestation) based on respiratory support required to maintain arterial oxygen saturation >89%.\n\n**Oxygen Therapy**\n\nSupplemental oxygen is prescribed to achieve normal oxygen saturation. Oxygen therapy results in quicker discharge, improved growth, and reduced desaturation episodes. Prevention of hypoxemia reduces the risk of pulmonary hypertension development.\n\n**Ventilation Strategy**\n\nEarly extubation is the goal for all preterm babies requiring mechanical ventilation. Gentle ventilation strategies and early, aggressive continuous positive airway pressure (CPAP) are used to reduce barotrauma.\n\n**Preventive Pharmacotherapy**\n\nAntenatal steroids are administered prenatally when possible. Early surfactant therapy is provided. Early caffeine therapy is considered. Systemic steroids are reserved for selective cases only.\n\n**Supportive Care**\n\nNutrition is optimized to support growth. Early stimulation is provided. Parental anxiety is addressed. Associated conditions including gastroesophageal reflux and [[259|patent ductus arteriosus]] are screened for and managed.\n\n**Monitoring for Complications**\n\nEchocardiography is performed to assess for pulmonary hypertension in established BPD. Signs of chronic respiratory insufficiency and cor pulmonale are monitored. High rehospitalization risk is anticipated in the first 2 years of life." } ] }, { "article_id": 199, "article_title": "Chronic Cough", "sections": [ { "title": "Clinical Assessment and Management", "content": "**Initial Evaluation**\n\n1. **Determine chronicity**: Confirm cough duration exceeds 4 weeks. Establish baseline: normal children without pathology experience 10–11 cough episodes daily; pathologic cough substantially exceeds this.\n\n2. **Age-directed history**:\n - **Infants**: Onset at birth or shortly after raises concern for [[155|congenital infection]] (cytomegalovirus, rubella) or airway anomalies. Chlamydia trachomatis [[150|pneumonia]] typically develops after the first month. Choking with feeding or emesis followed by cough suggests [[245|gastroesophageal reflux]].\n - **Toddlers and young children**: Inquire about foreign body aspiration, recurrent infections, and feeding difficulties.\n - **Older children**: Ask about psychogenic triggers (cough stopping with distraction or sleep is supportive of psychogenic cause).\n\n3. **Characterize the cough**: Determine if paroxysmal (typical of [[125|pertussis]] or [[184|cystic fibrosis]], often with vomiting), timing relative to feeding, and relationship to sleep or distraction.\n\n**Diagnostic Testing by Suspected Etiology**\n\n| Suspected Diagnosis | Recommended Tests |\n|---|---|\n| Allergy | Allergy skin test or blood-specific immunoglobulin E test |\n| Asthma | Pulmonary function testing, bronchial hyperreactivity test (e.g., methacholine challenge), exhaled nitric oxide, trial of asthma treatments |\n| Ciliary dyskinesia | Ciliary function tests |\n| Congenital anomalies | Bronchoscopy, chest radiography, CT/magnetic resonance imaging, angiography |\n| Cystic fibrosis | Sweat chloride test, genetic test |\n| Fungal infections | Organism-specific antibody assays (precipitin, complement fixation, immunoprecipitating); serum and urine antigen detection |\n| Foreign body | Chest radiography, bronchoscopy |\n| Gastroesophageal reflux | Barium swallow, 24-hour pH recording, bronchoalveolar lavage |\n| Idiopathic pulmonary fibrosis, autoimmune disease | Pulmonary function testing, diffusion CT, autoantibodies |\n\n**Management Principles**\n\n- Develop a partnership with the child and family to identify specific causes systematically.\n- Inform families that airway irritation causing chronic cough often takes time to resolve even after appropriate management; measure improvement in weeks, not days.\n- Direct therapy at the identified underlying cause.\n- If cough persists despite appropriate therapy, consider alternate diagnoses.\n- If cough recurs after appropriate therapy, consider endoscopic evaluation for underlying airway pathology." } ] }, { "article_id": 200, "article_title": "Concussion", "sections": [ { "title": "Management", "content": "**Immediate Assessment and Safety**\n\n- Any athlete suspected of concussion is removed from play immediately\n- Return to sport on the day of injury is not permitted\n- The athlete is not left alone in the initial hours; monitoring for deterioration continues\n\n**Diagnostic Evaluation**\n\n- The Acute Concussion Evaluation (ACE) is used in clinic or emergency department settings\n- Child-SCAT3 is applied for children aged 5–12 years or SCAT3 for older athletes\n- Computed tomography is obtained during initial evaluation if any of the following are present:\n - Deteriorating or [[142|altered mental status]]\n - Prolonged loss of consciousness\n - Repeated vomiting\n - Severe headache\n - Signs of skull fracture\n - Focal neurologic deficit\n - Severe mechanism of injury\n- CT is rarely indicated beyond 24 hours in uncomplicated cases\n\n**Management Strategy**\n\n- Rest, including cognitive rest, is encouraged\n- The ACE Care Plan is provided to parents and child for guidance\n- Strict return-to-activity guidelines are implemented, with gradual increase in both physical and mental activities\n\n**Follow-up and Specialist Referral**\n\n- Referral to a concussion specialist is made if:\n - Symptoms persist beyond 10–14 days\n - Symptoms worsen\n - The patient has a history of multiple concussions" } ] }, { "article_id": 201, "article_title": "Constipation", "sections": [ { "title": "Management", "content": "**Initial Assessment**\n\n1. A detailed history of stool frequency, consistency, and difficulty; pain or straining; and recent stressors or dietary changes is taken\n2. Physical examination is performed, including abdominal palpation and assessment of anal tone\n3. A stool sample is obtained for occult blood testing (note: false positives occur after rare red meat or peroxidase-containing vegetables)\n4. Fecal leukocytes are assessed (suggests infectious or inflammatory cause)\n\n**Distinguishing Functional from Organic Constipation**\n\nIf clinical features suggest Hirschsprung disease (delayed meconium passage in infancy, small ribbonlike stools, tight anal tone, failure to thrive), the following are considered:\n- Unprepared barium enema in very young infants with severe constipation\n- Manometry or rectal biopsy\n\nIf delayed meconium passage with Hirschsprung disease ruled out, the following are performed:\n- Sweat test or genetic testing for [[184|cystic fibrosis]]\n\n**Treatment of [[289|Functional Constipation]]**\n\nThree-pronged management is implemented:\n\n| Component | Intervention |\n|-----------|-------------|\n| **Behaviour** | Regular toileting practices are established; family dynamics and parental response are addressed; stool-withholding behaviour is managed |\n| **Diet** | Decreased: simple carbohydrates, refined/processed carbohydrates, saturated fat, processed meat, dairy (milk and cheese). Increased: fluid intake and dietary bulk |\n| **Medication** | An initial 'clean out' of retained stool is performed, then maintenance continues with stool softeners and agents to propel stool through colon |\n\n**When to Investigate Further**\n\nIf response to presumptive treatment with education, dietary changes, and medication is inadequate, or if concern for organic aetiology exists, further investigation proceeds." } ] }, { "article_id": 202, "article_title": "Corneal Abrasion", "sections": [ { "title": "Management", "content": "**Examination and Diagnosis**\n\n1. Topical anesthetic drops (proparacaine 0.5%) are instilled to facilitate examination and provide temporary pain relief\n2. Fluorescein dye is instilled using either:\n - Dry impregnated strip (preferred): wetted with water, normal saline, or Ringer's solution, then gently touched to pink palpebral conjunctiva of lower lid or bulbar conjunctiva\n - Liquid drop form\n3. Examination is under blue-filtered light (cobalt blue on direct ophthalmoscope, slit lamp, or Wood lamp)\n4. The upper eyelid is everted to inspect for foreign bodies\n5. The lower eyelid is retracted to inspect inferior conjunctiva\n6. Vision testing is performed\n\n**Treatment**\n\n1. **Topical antibiotic ointment**: Applied frequently until the epithelium is completely healed\n - For contact lens wearers: topical fluoroquinolones are used to cover Pseudomonas species\n\n2. **Oral analgesia**: Initiated in all cases for pain control\n\n3. **Topical cycloplegic agent** (for large abrasions): Cyclopentolate hydrochloride 1% relieves pain from ciliary spasm\n\n4. **Foreign body removal** (if present):\n - Superficial foreign bodies: removed with moist cotton-tipped applicator\n - Deeper foreign bodies: referred to an ophthalmologist\n\n**Important Notes**\n\n- Topical anesthetic drops are not sent home with the patient—they retard epithelial healing and inhibit blinking reflex\n- Semipressure patch is not used—it does not improve healing time or decrease pain, and may itself cause abrasion\n- Referral to an ophthalmologist is made if vision changes are present or if a deeper foreign body is suspected" } ] }, { "article_id": 203, "article_title": "Cyclic Vomiting Syndrome", "sections": [ { "title": "Management", "content": "**Initial Assessment**\n\n1. The pattern is confirmed: history of episode frequency, duration, timing of onset, and intervening symptom-free periods is obtained\n2. Warning signs requiring urgent investigation are assessed:\n - Severe abdominal pain\n - Bilious or bloody vomiting\n - [[142|Altered mental status]] or neurological signs\n - Fever or signs of systemic illness\n\n**Baseline Investigations (if CVS criteria met and no warning signs)**\n\n- Upper gastrointestinal series (to exclude malrotation)\n- Serum electrolytes, blood urea nitrogen, creatinine\n- If warning signs are present: liver and pancreatic function tests, abdominal imaging (ultrasound ± CT/MRI), and oesophagogastroduodenoscopy are added or considered\n- If metabolic triggers are suspected (fasting, high-protein meals, intercurrent illness): a serum and urine metabolic panel (lactate, ammonia, carnitine profile, amino acids, organic acids) is obtained **prior to IV fluid treatment**\n- If neurological abnormalities are present: brain MRI and neurology consultation are obtained\n\n**Acute Episode Management**\n\n**Prodromal phase (if recognised):**\n- A 5HT3 antagonist antiemetic is administered:\n - Ondansetron or granisetron (specific doses not provided in passages)\n\n**Active vomiting phase:**\n- Intravenous fluid rehydration (primary treatment; most episodes respond promptly)\n- 5HT3 antagonist antiemetic (ondansetron or granisetron)\n- Sedation with lorazepam if needed\n- Analgesia as necessary for pain\n- Serum urea and electrolytes are monitored during treatment\n\n**Expected course:** Episodes typically resolve within 24–48 hours with supportive care." } ] }, { "article_id": 204, "article_title": "Depression", "sections": [ { "title": "Assessment and management", "content": "**Initial evaluation**\n\n1. Detailed clinical history is obtained, including mood, functioning, and change from baseline\n2. Mental status examination is performed\n3. Suicidal ideation and self-harm risk are screened for\n4. Psychotic features are assessed by asking directly: \"Do you ever feel your eyes or ears play tricks on you?\"\n5. Family history of depression, anxiety, and suicide is taken\n6. Environmental stressors and adverse childhood experiences are identified\n7. Comorbid anxiety, ADHD, [[286|conduct disorder]], and chronic medical conditions are screened for\n8. A validated screening tool is used as an adjunct (PHQ-9: Modified for Teens, Beck Depression Inventory, or Children's Depression Inventory)\n\n**Referral for definitive diagnosis**\n\nReferral is made to a psychiatrist or psychologist for formal diagnostic assessment and treatment planning.\n\n**Treatment initiation**\n\n**Psychotherapy (first-line for mild-to-moderate symptoms)**\n- Cognitive behaviour therapy (CBT) — strongest evidence\n- CBT combined with parental involvement\n- Family therapy\n- For toddlers and young children: parent–child relational therapy\n- Alternative approaches with good support: client-centred therapy, interpersonal therapy, relaxation techniques\n\n**Pharmacotherapy (for moderate-persistent or severe symptoms)**\n\nAntidepressant medications may be indicated. Positive family history of depression increases likelihood of response. Specific dosing and medication selection are determined by the psychiatrist.\n\n**Psychoeducation for family**\n\n- Depression is explained as common and not due to lack of coping ability or personal strength\n- Family history is discussed to reduce stigma\n- Symptoms are clarified as real, not fabricated\n- Apparent laziness or irritability are explained as symptoms, not character flaws\n- Hopelessness is emphasised as a symptom, not reality\n- Reassurance is given that treatment works, though improvement takes several weeks\n- The affected individual is often the last to recognise improvement" } ] }, { "article_id": 205, "article_title": "Drug Reaction", "sections": [ { "title": "Management", "content": "**Immediate assessment:**\n- The temporal relationship between drug exposure and symptom onset is identified\n- IgE-mediated reactions occur within minutes and require prior sensitization; rashes developing after several days of therapy are seldom IgE-mediated\n- DRESS typically begins 2–8 weeks after drug initiation\n\n**For suspected IgE-mediated [[143|anaphylaxis]]:**\n- The offending drug is discontinued immediately\n- Supportive care and airway management are provided as needed\n\n**For DRESS:**\n- **Primary intervention:** The offending drug is discontinued immediately\n- Similar cross-reacting drugs are avoided\n- Supportive care is provided\n- Systemic glucocorticoids are considered (evidence is limited but believed effective)\n- Persistent or worsening symptoms are monitored, as these may continue for weeks to months after drug withdrawal\n- Multiorgan involvement is assessed, particularly hepatic and renal function\n\n**For other cutaneous drug reactions:**\n- The offending drug is discontinued\n- Most reactions confined to the skin resolve without sequelae after drug withdrawal\n- Supportive care is provided" } ] }, { "article_id": 206, "article_title": "Epilepsy", "sections": [ { "title": "Management", "content": "### Initial Assessment\n\nWhen a child presents with a first seizure, whether it was provoked or unprovoked is established. A detailed history of the event is obtained, including duration, type of movements, consciousness level, and postictal state. Neurological examination is performed and EEG is considered to help categorize seizure type and epilepsy type.\n\n### Diagnosis and Investigation\n\nEpilepsy diagnosis requires either:\n- Two unprovoked [[315|seizures]] separated by >24 hours, OR\n- One unprovoked seizure with ≥60% recurrence risk based on clinical, EEG and/or MRI findings, OR\n- Confirmed epilepsy syndrome\n\nInterictal EEG is performed when epilepsy is diagnosed, to help categorize the epilepsy type. Ictal EEG may support diagnosis if available.\n\n### Treatment Initiation\n\nAntiepileptic drug therapy can be initiated following the first seizure in certain situations where recurrence risk is high (≥60%) or when two seizures have occurred. Approximately 65–70% of children with epilepsy will achieve seizure remission with appropriate medication.\n\n### Special Considerations\n\nFor epileptic encephalopathy with continuous spike waves in slow-wave sleep (CSWS), where discharges occur in >85% of slow-wave sleep (electrical status epilepticus in sleep or ESES):\n- Nocturnal diazepam 0.2–0.5 mg/kg orally at bedtime for several months is often used as first- or second-line therapy\n- Valproic acid and benzodiazepines are commonly used but evidence favours steroids and nocturnal diazepam for associated aphasia\n- Some children respond to valproic acid combined with clobazam or to levetiracetam" } ] }, { "article_id": 207, "article_title": "Erythema Toxicum Neonatorum", "sections": [ { "title": "Management", "content": "**Assessment**\n\nErythema toxicum neonatorum is a clinical diagnosis. Rash distribution, morphology, and timing of onset are examined. The diagnosis is confirmed if needed by obtaining a Wright-stained smear of intralesional contents to demonstrate eosinophils and exclude organisms.\n\n**Treatment**\n\nNo therapy is required. The condition resolves spontaneously within 3–7 days. Parents are reassured that the rash is benign and self-limited.\n\n**Monitoring**\n\nNo specific follow-up is necessary. Lesions resolve without intervention, scarring, or pigmentation changes." } ] }, { "article_id": 208, "article_title": "Femur Fracture", "sections": [ { "title": "Management", "content": "**Initial Assessment and Stabilization**\n\n1. **Primary survey**: Assess hemodynamic status immediately. Femur fractures can cause significant blood loss.\n2. **Neurovascular examination**: Perform thorough assessment before and after any manipulation.\n3. **Imaging**: Obtain anteroposterior and lateral radiographs of the femur (including hip and knee). Also obtain anteroposterior radiograph of the pelvis to rule out associated fractures.\n4. **Immobilization**: Apply posterior leg splint or traction and splinting to minimize blood loss and prevent further injury.\n5. **Orthopedic consultation**: Arrange urgent consultation for all femur fractures.\n\n**Age-Specific Definitive Management**\n\n| Age Group | Initial Management | Definitive Treatment |\n|-----------|-------------------|----------------------|\n| Birth to 2 years | Traction or splinting | Pavlik harness or spica casting |\n| 2 to 6 years | Traction or splinting | Spica casting |\n| 6 to 11 years | Traction or splinting | Intramedullary nailing |\n| Adolescents | Traction splint or posterior leg splint | Surgical stabilization with internal fixation |\n\n**Special Considerations**\n\n- In children under 2 years with femur fracture, assess for signs of nonaccidental trauma and consider child protection involvement.\n- In high-energy trauma with hemodynamic instability, investigate for other sources of bleeding beyond the femur fracture.\n- Hospitalization for skeletal traction is typically required before definitive fixation or casting." } ] }, { "article_id": 209, "article_title": "Hemophilia", "sections": [ { "title": "Management", "content": "**Triage and Initial Assessment**\n\nBleeding emergencies in hemophilia patients require prompt identification and treatment. Factor replacement should be infused prior to completing radiologic evaluation to avoid unnecessary delays. Life- and limb-threatening bleeds include [[379|intracranial hemorrhage]], iliopsoas bleeds, gastrointestinal bleeds, and [[328|compartment syndrome]].\n\n**Factor Replacement Dosing**\n\nThe primary treatment is infusion of factor VIII or factor IX concentrate (lyophilized powder from recombinant-DNA or plasma-derived sources).\n\nTarget hemostatic factor levels:\n- Mild to moderate bleeding: 35% to 50%\n- Severe, life-threatening bleeding, or surgical procedures: 100%\n\n**Specific Bleeding Sites**\n\n| Bleeding Type | Management |\n|---|---|\n| Hemarthrosis (joint bleed) | Factor replacement + immobilization + ice |\n| Oral bleeding | Topical thrombin + antifibrinolytic therapy; add factor if insufficient |\n| Iliopsoas/thigh hemorrhage | Factor replacement; early hematology consultation; monitor for compartment syndrome |\n| Hematuria | Factor replacement |\n| Throat/neck swelling | Factor replacement; early hematology consultation |\n| Emergent/major surgery | Factor replacement to achieve 100% hemostatic levels; early hematology consultation |\n\n**Special Considerations**\n\n- Patients with inhibitors (antibody development): early hematology consultation required for management strategy\n- Early hematology consultation is warranted for any patient anticipated to need operative or procedural intervention\n- Prophylactic factor replacement is standard of care for severe hemophilia; initiated before 2 years of age to prevent progressive joint damage" } ] }, { "article_id": 210, "article_title": "Herpes Simplex Virus Infection", "sections": [ { "title": "Management", "content": "**Assessment and diagnosis**\n\nClinical presentation is identified: vesicular lesions on erythematous base (typically grouped), oral ulceration (gingivostomatitis), or systemic symptoms. In neonates, timing of presentation is determined (5–14 days suggests localised SEM disease; 14–28 days suggests CNS involvement). Maternal history of genital herpes and immunity status is obtained where possible.\n\n**Risk stratification**\n\nHigh-risk groups requiring urgent evaluation and treatment are identified:\n- Neonates with any signs of infection\n- Immunocompromised children\n- Children with severe systemic symptoms or CNS involvement\n- Neonates born to mothers with primary genital HSV at delivery (25–50% transmission risk)\n\n**Treatment**\n\nAciclovir is indicated for severe symptomatic skin, ophthalmic, cerebral, and systemic infections. Specific dosing regimens are not detailed in the provided passages; current formulary guidance should be consulted for age-appropriate and weight-based dosing.\n\nFor neonates and immunocompromised children with suspected or confirmed HSV infection, aciclovir is initiated promptly given the risk of severe or life-threatening disseminated disease.\n\n**Supportive care**\n\nPain and fever are managed symptomatically. Most primary infections in immunocompetent hosts are self-limiting; HSV esophagitis in those with normal immune function typically resolves spontaneously within 1–2 weeks." } ] }, { "article_id": 211, "article_title": "Hypovolemic Shock", "sections": [ { "title": "Bedside Management", "content": "**Immediate steps:**\n\n1. **Airway and breathing:** The airway is ensured open and clear; intubation is considered if needed. Oxygen is administered via nonrebreather mask at 10–15 L/min.\n\n2. **Position:** If hypotensive, the child is placed in Trendelenburg position (unless breathing is compromised). If stable, the child remains in a position of comfort with the caregiver.\n\n3. **Vascular access:** Intravenous or intraosseous access is established.\n\n4. **Initial fluid bolus:** Isotonic crystalloid (0.9% sodium chloride or lactated Ringer's solution) is given at **20 mL/kg body weight** (maximum 1 L bolus) over 5–10 minutes.\n\n5. **Reassess:** Perfusion is checked (pulses, capillary refill, skin temperature, urine output, mental status).\n\n**Repeat boluses:** If perfusion has not normalized, the 20 mL/kg bolus is repeated. In nonhemorrhagic hypovolemic shock, up to 40 mL/kg may be needed before response occurs. Typically no more than 60 mL/kg is required, though more may be necessary with ongoing losses.\n\n**Blood transfusion:** In trauma patients who do not respond to initial crystalloid bolus, packed red blood cells are transfused. Specific volumes are not defined in the literature.\n\n**Monitoring and reassessment:** Frequent clinical reassessment guides ongoing therapy. Pressors are not required in simple hypovolemic shock.\n\n**Special note for newborns:** An emergency umbilical catheter is placed and volume expansion is given with 0.9% sodium chloride or emergency non-cross-matched type-O, Rh-negative packed red blood cells in aliquots of **10 mL/kg** given over 5–10 minutes." } ] }, { "article_id": 212, "article_title": "Intellectual Disability", "sections": [ { "title": "Assessment and Diagnosis", "content": "**Initial evaluation:**\n\n1. Detailed developmental history is obtained, including pregnancy, birth history, and achievement of [[10|developmental milestones]] across motor, cognitive, language, and social domains\n2. Detailed family history is obtained and assessed for familial or reproductive history suggestive of chromosomal rearrangements\n3. Complete physical examination is performed, evaluating specifically for dysmorphic features and [[115|congenital anomalies]]\n4. Newborn screening results are reviewed\n\n**Cognitive and adaptive assessment:**\n\n- Standardized intelligence testing is administered (generally possible at age 3–4 years or older)\n- Adaptive behavior is assessed across conceptual, social, and practical domains\n- Deficits are documented as manifesting during the developmental period and causing functional impairment\n\n**Diagnostic considerations:**\n\n- Cultural, linguistic, sensory, motor, and behavioral factors that may affect assessment are accounted for\n- In children younger than 5 years with delays in two or more developmental domains, the term \"global [[82|developmental delay]]\" is used rather than intellectual disability\n- Diagnosis is recognized as potentially challenging in children with comorbid [[117|autism spectrum disorder]], behavioral issues, language disorders, or [[94|mental health]] conditions\n\n**Further investigation if indicated:**\n\n- Chromosomal microarray analysis (CMA) if dysmorphic features or [[115|congenital anomalies]] are present\n- Banded karyotype analysis if familial or reproductive history suggests chromosomal rearrangements\n- Metabolic evaluation as clinically indicated\n- Fragile X testing if suggested by clinical features\n- Neuroimaging if clinically warranted\n- Genetic consultation for complex cases\n- Whole exome sequencing is considered for cases with features suggesting a specific genetic diagnosis\n\n**Early intervention:**\n\n- Infants and young children with delayed cognitive development are referred to early intervention programs to increase the probability of functional improvements over time" }, { "title": "Support and Management", "content": "**Educational and functional planning:**\n\n- Individualized education programs (IEP) or individualized family service plans (IFSP) are developed as appropriate\n- Limitations often coexist with strengths; supports are determined based on identified limitations\n- Supports are implemented across multiple settings (home, school, community) rather than restricted to structured environments\n\n**Communication support:**\n\n- Need for augmentative and alternative communication (AAC) supports is assessed\n- AAC use can be beneficial for at least 30% of school-age individuals requiring such supports\n- AAC use is generalized across all settings to maximize functional communication\n\n**Inclusive environment:**\n\n- Participation in inclusive environments typical of same-age peers is facilitated\n- Appropriate supports are provided to enable individuals to live and learn successfully in community settings\n- Individuals with intellectual disability can gain functional skills over time with appropriate support systems in place" } ] }, { "article_id": 213, "article_title": "Long Qt Syndrome", "sections": [ { "title": "Clinical Assessment and Management", "content": "**Initial Evaluation**\n\nLong QT syndrome is suspected in any child presenting with:\n- Unexplained [[334|syncope]], particularly during exertion, emotion, or sleep\n- [[315|Seizures]] without clear neurological cause\n- Palpitations\n- Family history of sudden cardiac death or syncope\n- Cardiac arrest\n\n**Electrocardiography**\n\nA resting 12-lead ECG is obtained immediately. The QT interval is measured and the corrected QT interval (QTc) is calculated using the Bazett formula: QTc = QT/√(RR interval).\n\nInterpretation is as follows:\n- QTc <0.45 seconds in males: normal\n- QTc <0.46 seconds in females and children <15 years: normal\n- QTc >0.46 seconds in females and children <15 years: prolonged\n- QTc >0.45 seconds in males: prolonged\n- QTc >0.48 seconds with [[334|syncope]]: highly suggestive of long QT syndrome\n\n**Further Diagnostic Testing**\n\n- 24-hour ambulatory ECG (Holter monitor) to assess QT interval variability and detect arrhythmias\n- Exercise stress testing to evaluate QT response to exertion and identify exercise-triggered events\n- Genetic testing for pathogenic variants in KCNQ1, KCNH2, SCN5A, and other genes; useful for family screening, with a 25% false negative rate\n\n**Electrolyte Assessment**\n\nIn any patient with QT prolongation, serum potassium, calcium, and magnesium are measured to exclude acquired causes, and any deficiencies are corrected.\n\n**Family Screening**\n\nECG is performed on first-degree relatives. Genetic testing should be offered to family members of confirmed cases.\n\n**Treatment Principles**\n\nAsymptomatic patients with a prolonged QT interval and positive family history are treated to prevent sudden death. Management is individualised based on genetic subtype and symptom triggers. Medications known to prolong QT interval (class Ia and III antiarrhythmics, azithromycin, and others) are avoided. Electrolyte abnormalities are corrected and underlying causes of acquired QT prolongation are addressed." } ] }, { "article_id": 214, "article_title": "Malnutrition", "sections": [ { "title": "Assessment and Documentation", "content": "**Initial Assessment**\n\n1. Complete family and patient history is obtained\n2. Full physical examination is performed\n3. Anthropometrics are measured (weight, height, BMI)\n4. BMI z-score is calculated\n\n**Formal Documentation in Medical Record**\n\nThe diagnosis is stated as: [degree of malnutrition] related to [underlying cause] as evidenced by [supporting evidence]\n\nExample: Moderate malnutrition related to congenital heart disease as evidenced by a BMI z-score of –2.5\n\n**Classification**\n\nMalnutrition is classified as:\n- Primary (socioeconomic) or secondary (disease-related)\n- Illness-related or non-illness related\n- Acute (<3 months) or chronic (>3 months)" }, { "title": "Management Strategy", "content": "**For Non-Illness-Related Malnutrition**\n\n1. Environmental and familial psychosocial factors are addressed\n2. An observed feeding trial with age-appropriate diet is implemented\n3. Response to intervention is assessed\n\n**Intervention Framework**\n\nBoth nutrition-specific and nutrition-sensitive approaches are considered:\n\n- **Nutrition-specific interventions**: food fortification, supplementation\n- **Nutrition-sensitive interventions**: education, clean water access, sanitation, agriculture programs, regulatory interventions, deworming\n\n**Coordination**\n\nCollaboration with government, nongovernment, national, and international organizations occurs where possible to maximize intervention success." } ] }, { "article_id": 215, "article_title": "Melanoma", "sections": [ { "title": "Clinical Assessment and Management", "content": "**Recognition and Referral**\n\nSuspicious skin lesions are identified by their appearance: red-brown-black colour with diffuse periphery, crusting, bleeding, pain, or itching. Particular attention is paid to rapid changes in size, shape, or other characteristics of existing nevi.\n\nAny suspicious lesion warrants prompt referral for specialist evaluation and possible biopsy. Referral is not delayed pending observation of lesion changes.\n\n**Risk Stratification**\n\nPatients at higher risk are identified:\n- Personal or family history of atypical mole–melanoma syndrome\n- Xeroderma pigmentosum\n- Giant congenital melanocytic nevi\n- History of immunosuppression, [[122|immunodeficiency]], radiation therapy, or stem cell transplant\n- Multiple acquired nevi or dysplastic nevi\n\nThese patients require more frequent clinical surveillance and photographic documentation.\n\n**Prevention Counselling**\n\nAll patients and families are given prevention advice:\n- Intense midday sun exposure between 10 am and 3 pm is avoided\n- Protective clothing is worn: hat, long sleeves, and pants\n- Sunscreen is used (specific formulations and SPF not detailed in available guidance)\n- Adolescents are specifically counselled against tanning booth use\n\n**Surveillance**\n\nFor at-risk patients, frequent clinical examinations with photographic documentation are arranged to enable detection of changes over time. A schedule appropriate to individual risk level is established, with prompt evaluation of any reported changes." } ] }, { "article_id": 216, "article_title": "Meningococcemia", "sections": [ { "title": "Management", "content": "**Empiric Antibiotic Therapy**\n\nCeftriaxone is the drug of choice for empiric therapy when meningococcus is considered. Penicillin G can be used as an alternative.\n\n**Prophylaxis for Close Contacts**\n\nWhen prophylaxis is indicated for close intimate contacts, household members, or those with direct exposure to patient secretions, one of the following is administered:\n\n- **Rifampin**: 10 mg/kg (maximum dose 600 mg) orally every 12 hours for 2 days\n- **Ceftriaxone**: 125 mg intramuscularly as a single dose for children under 15 years of age\n\n**Diagnostic Approach**\n\nBlood cultures are obtained and Gram stain of petechial scrapings is performed, which may reveal gram-negative diplococcal organisms (*Neisseria meningitidis*).\n\n**Supportive Care**\n\nHypotension, shock, and disseminated intravascular coagulation are managed with appropriate supportive measures. Complications including adrenal insufficiency, neurologic sequelae, and tissue necrosis requiring possible surgical intervention are monitored for." } ] }, { "article_id": 217, "article_title": "Migraine Headache", "sections": [ { "title": "Management", "content": "**Acute Treatment**\n\nTriptans (serotonin receptor agonists) are the first-line treatment for [[308|migraine]]. Sumatriptan can be administered via multiple routes:\n- Intranasally: 5 mg per dose\n- Orally: 25 mg per dose\n- Intradermally: 0.1 mg/kg per dose\n\nIf necessary, the dose may be repeated after 2 hours.\n\n**General Approach**\n\nFor patients with a known diagnosis of migraine, the main clinical issue is typically pain control. However, any significant change in the quality, severity, or timing of headaches warrants appropriate investigation to exclude secondary pathology.\n\nHeadaches that raise concern for primary CNS pathology and require urgent evaluation include those that:\n- Wake the child from sleep\n- Are worse in the morning or improve over the course of the day\n- Are worse when recumbent or with a Valsalva maneuver\n- Have sudden onset with severe intensity (thunderclap headache)\n\nSudden-onset severe headache demands urgent evaluation to rule out subarachnoid hemorrhage or venous sinus thrombosis.\n\n**Prophylactic Treatment**\n\nA combination of acute and prophylactic treatment strategies is recommended, though specific prophylactic regimens are not detailed in the available passages." } ] }, { "article_id": 218, "article_title": "Nicotine Dependence", "sections": [ { "title": "Management", "content": "**Assessment and Referral**\n\nIdentify dependence using validated adolescent-specific instruments such as the Modified Fagerström Tolerance Questionnaire or Hooked on Nicotine Checklist. Adolescents who smoke fewer than a pack of cigarettes daily and do not experience craving within 30 minutes of waking may not require pharmacotherapy and can be managed with counseling alone.\n\n**Pharmacotherapy Options**\n\nFor adolescents with established nicotine dependence, offer nicotine-replacement therapy:\n- Nicotine gum\n- Transdermal nicotine patch\n\nAlternatively, sustained-release bupropion may be used.\n\nThese medications suppress withdrawal symptoms while the adolescent develops coping strategies.\n\n**Behavioral Support**\n\nCombine pharmacotherapy with counseling and skills training focused on managing withdrawal symptoms and coping with triggers. Patients with more severe addiction or limited coping ability benefit most from combined pharmacotherapy and counseling.\n\n**Referral**\n\nProviders uncomfortable prescribing or monitoring nicotine-replacement therapies should refer adolescents with dependence to community smoking cessation programs or telephone quit lines for specialized management." } ] }, { "article_id": 219, "article_title": "Occult Fracture", "sections": [ { "title": "Management", "content": "**Initial assessment**\n- Thorough clinical examination is performed: swelling, localised tenderness, and functional impairment are documented\n- Radiographs are obtained in at least two planes (anterior/posterior and lateral)\n- Soft tissue swelling is examined to localise injury\n- At the elbow: posterior fat pad sign, anterior fat pad elevation ('sail sign'), and anterior humeral line displacement are assessed\n- At the ankle: lateral swelling suggesting lateral malleolus fracture is noted\n\n**Immediate management of suspected occult fracture**\n- The affected limb is immobilised with splint or cast\n- The limb is elevated\n- Analgesia is provided as needed\n- Immobilisation typically results in significantly reduced pain\n\n**Follow-up imaging**\n- Follow-up radiographs are scheduled at 7–10 days to assess for callus formation\n- For rib fractures, radiographic visibility is expected over 2 weeks\n- For toddler's fracture (spiral tibia fracture): diffuse new periosteal bone formation is expected, evident 3 weeks after injury\n\n**Duration of immobilisation**\n- Three weeks of splint or cast immobilisation for most occult fractures\n- Three to four weeks in a long-leg, weight-bearing cast for toddler's fracture of the tibia\n\n**Safeguarding**\n- If nonaccidental trauma is suspected, the child protection team is consulted\n- In children under 24 months with suspected abuse: skeletal survey is arranged\n- If initial skeletal survey is normal but concern for occult injury persists: a repeat survey is arranged at 2 weeks (skull, spine, and pelvis films are omitted on repeat to reduce radiation)" } ] }, { "article_id": 220, "article_title": "Pediatric Nutrition", "sections": [ { "title": "Nutritional Assessment and Support", "content": "**Initial Assessment**\n\nDetailed history of dietary intake and feeding practices is obtained. Nutritional status is classified using weight-for-length or weight-for-age measurements as appropriate to age. Signs of specific micronutrient deficiencies are assessed.\n\n**Feeding Route Selection**\n\nWhen nutritional support is indicated, enteral feeding is used if the gastrointestinal tract is functional. Parenteral nutrition is reserved for situations where enteral access is not possible or tolerance cannot be achieved.\n\n**Monitoring During Support**\n\nOverfeeding in critically ill children is avoided, as this can be counterproductive. Tolerance of enteral feeds is monitored and composition is adjusted as needed. For children receiving parenteral nutrition, the formulation is individualized based on clinical status and metabolic needs rather than relying on standard protocols alone.\n\n**Special Populations**\n\nChildren with developmental disabilities may require modified feeding approaches and texture modifications. Those with chronic conditions (renal disease, cancer, [[254|inflammatory bowel disease]]) need disease-specific nutritional adjustments. Bone health status is assessed in children with chronic illness and micronutrient intake is optimized accordingly." } ] }, { "article_id": 221, "article_title": "Pediatric Rheumatology", "sections": [ { "title": "Clinical Assessment and Management", "content": "**Initial Evaluation**\n\nBegin with a detailed history and thorough physical examination. These remain the cornerstone of diagnosis in pediatric rheumatology and should be systematic and comprehensive.\n\n**Investigations**\n\nOrder serological testing selectively based on clinical suspicion:\n- Antinuclear antibody testing when indicated by clinical features\n- Anti-CCP2 antibodies when early rheumatoid arthritis is suspected\n- Ophthalmologic examination in children with juvenile rheumatoid arthritis\n\n**Referral Criteria**\n\nRefer to a pediatric rheumatologist when:\n- Unexplained systemic inflammation is present or has occurred\n- Organ involvement is unexplained\n- Systemic vasculitis is suspected\n\n**Pharmacological Management**\n\nFor vascular manifestations in rheumatic conditions, the following agents may be used:\n- Calcium channel blockers (nifedipine, amlodipine)\n- Phosphodiesterase-5 inhibitors (sildenafil, tadalafil)\n- Angiotensin receptor antagonists (losartan)\n- Topical nitrates (glyceryl trinitrate)\n- Prostacyclins (iloprost, epoprostenol)\n- Endothelin receptor antagonists (bosentan, ambrisentan, macitentan)\n- ACE inhibitors (captopril, enalapril)\n\nSpecific dosing and route selection should be determined by the treating rheumatologist based on the individual condition and patient factors.\n\n**Rehabilitation**\n\nConsider admission to rehabilitation if there is inadequate response to outpatient occupational or physical therapy." } ] }, { "article_id": 222, "article_title": "Precocious Puberty", "sections": [ { "title": "Clinical Assessment and Management", "content": "**Initial Evaluation**\n\n1. **History and physical examination** are the foundation. Age of onset, tempo of development, growth pattern, and any neurological symptoms are documented. Examination is for café-au-lait spots, bony deformities, and focal neurological deficits.\n\n2. **Risk stratification**: Girls aged 7–8 years with normal history and physical examination findings can be observed without further workup. Referral to [[124|pediatric endocrinology]] is made if:\n - Age <6 years (black girls) or <7 years (white girls)\n - Rapid tempo of pubertal progression\n - Growth retardation (suggests [[171|hypothyroidism]] or GH deficiency)\n - Neurological signs or symptoms\n - Concern for exogenous hormone exposure\n\n**Diagnostic Testing** (when indicated)\n\n- **Bone age radiograph**: Obtained if advanced bone age (>2 years ahead of chronological age) is suspected\n- **Basal LH and FSH**: Elevated levels indicate central precocious puberty; suppressed levels indicate peripheral precocious puberty\n- **GnRH stimulation test**: Performed if basal gonadotropins are borderline or if central precocious puberty is suspected. Elevated LH response confirms central precocious puberty; prepubertal response suggests peripheral precocious puberty\n- **Thyroid function (T4, TSH)**: Used to screen for [[171|hypothyroidism]]\n- **17-OHP, DHEA, androstenedione**: Obtained if adrenal pathology is suspected\n- **Pelvic ultrasound**: Used to identify ovarian tumors or cysts\n- **Abdominal ultrasound**: Used to identify adrenal masses\n- **Cranial MRI**: Indicated for CNS evaluation if central precocious puberty is confirmed, especially with very early onset, rapid progression, or neurological findings\n\n**Management Principles**\n\nThe evaluation and ongoing management of precocious puberty is best coordinated with a pediatric endocrinologist. Treatment decisions depend on the underlying etiology, age at presentation, and rate of progression. Specific pharmacological interventions and dosing are determined by the endocrinology team." } ] }, { "article_id": 223, "article_title": "Recurrent Pneumonia", "sections": [ { "title": "Clinical Evaluation and Management", "content": "**Initial Assessment**\n\n1. **Confirm the diagnosis**: All previous chest radiographs are obtained and reviewed together by a pediatric radiologist with clinical context. Radiographic clearing is confirmed to have occurred between episodes, to distinguish recurrence from persistence.\n\n2. **Focused history**: Specific questioning covers foreign body aspiration, [[107|asthma]] symptoms, signs of malabsorption ([[104|failure to thrive]], steatorrhoea), cough with feeding, choking episodes, and [[245|gastroesophageal reflux]] symptoms.\n\n3. **Physical examination**: Respiratory rate and lung sounds are assessed. Nutritional status is evaluated, neurologic examination is performed, and clubbing is sought.\n\n4. **Radiographic pattern recognition**: The pattern is classified as (1) recurrent infiltrates in the same location, (2) recurrent dense infiltrates in different locations, or (3) recurrent interstitial infiltrates. This guides further testing.\n\n**Tailored Investigation**\n\nBased on clinical suspicion, investigations are ordered in this sequence:\n\n- **Suspected aspiration**: Videofluoroscopic swallow study (with speech therapist) or fiberoptic endoscopic evaluation of swallowing; oesophagography, upper gastrointestinal series, gastric emptying study, or pH/impedance probe are considered\n- **Suspected airway obstruction or [[107|asthma]]**: Pulmonary function testing with flow-volume loops before and after bronchodilator, lung volume studies, and challenge tests (exercise, methacholine, or cold air)\n- **Suspected [[184|cystic fibrosis]]**: Sweat chloride test or DNA analysis\n- **Suspected primary ciliary dyskinesia**: Fractional nasal exhaled nitric oxide, electron microscopy of respiratory cilia, and DNA analysis\n- **Suspected [[122|immunodeficiency]]**: Immunodeficiency screening panel\n- **Structural abnormalities**: Chest computed tomography with expiratory images; flexible bronchoscopy with bronchoalveolar lavage if diagnosis remains unclear\n\n**Referral Criteria**\n\nReferral to [[123|pediatric pulmonology]] is made if the child has:\n- Recurrent [[150|pneumonia]] or persistent chest radiographic abnormality\n- Dysphagia, coughing, or choking with feedings\n- Recurrent wheezing not responsive to routine [[107|asthma]] therapy\n\nFor complex cases, referral to a multidisciplinary aerodigestive team (pulmonologist, otolaryngologist, gastroenterologist, speech-language pathologist) is considered.\n\n**Admission Criteria**\n\nHospital admission is indicated for:\n- Clinically significant dyspnoea\n- Hypoxaemia\n- Worsening pulmonary signs or symptoms\n- Equivocal history\n- Acute life-threatening event\n\nThese findings may indicate acute or cumulative effects of chronic aspiration." } ] }, { "article_id": 224, "article_title": "Scoliosis", "sections": [ { "title": "Clinical Assessment and Management", "content": "**Initial Evaluation**\n\nThe child is examined for visible trunk asymmetry, rib hump (thoracic involvement), or flank prominence (lumbar involvement). Associated features suggesting syndromic or neuromuscular scoliosis are assessed, including skin manifestations (neurofibromatosis), skeletal features (Marfan syndrome), or neurological signs.\n\nA standing posteroanterior radiograph of the spine is obtained to measure the Cobb angle. Curves measuring less than 10 degrees represent spinal asymmetry and do not require further imaging or orthopedic follow-up.\n\n**Curve Classification and Prognosis**\n\nCurves of 10 degrees or greater constitute scoliosis. Whether the curve is functional (flexible, correctable) or structural (fixed) is determined. The anatomic location (thoracic, lumbar, or cervical) and direction of convexity are identified.\n\nFor idiopathic scoliosis, skeletal maturity is assessed and family history is documented. Girls with idiopathic scoliosis are at higher risk for curve progression than boys.\n\n**Management by Curve Severity**\n\nFor arthrogryposis-associated scoliosis:\n- Curves <30 degrees: initial management with thoracolumbar spinal orthosis (TLSO) brace is considered\n- Curves >40 degrees: surgical fusion is generally indicated\n\n**Monitoring for Complications**\n\nIn severe or progressive scoliosis, particularly neuromuscular forms, respiratory function is assessed. Thoracic curves with Cobb angles ≥35 degrees carry risk for restrictive lung disease. Children with progressive neuromuscular disease (such as [[242|Duchenne muscular dystrophy]]) require close monitoring for respiratory compromise and potential cor pulmonale.\n\n**Specialist Referral**\n\nReferral to orthopedic surgery is made for curves requiring intervention. Multidisciplinary team involvement is recommended for severe cases, syndromic scoliosis, or scoliosis associated with significant comorbidities." } ] }, { "article_id": 225, "article_title": "Seizure Disorder", "sections": [ { "title": "Management", "content": "**Initial Assessment and Stabilization**\n\nAll treatable causes of seizure are rapidly considered. Baseline neurologic examination findings are obtained. Focal neurologic findings, persistent altered mental status, or signs of increased intracranial pressure are assessed.\n\n**Consultation Triggers**\n\nReferral to neurology is made for: focal neurologic findings, persistent altered mental status, status epilepticus, [[292|febrile seizure]] in infants younger than 6 months, afebrile seizure in patients younger than 24 months, concern for [[301|infantile spasms]], or recurrent seizures.\n\nReferral to neurosurgery is made for signs of increased intracranial pressure or abnormal head imaging findings.\n\n**Diagnostic Workup**\n\nElectroencephalography is performed for seizure classification and characterization. For children aged 6–12 months who are well-appearing and fully immunized with simple febrile seizure, lumbar puncture is not routinely recommended. Lumbar puncture is considered as an option for children with incomplete or unknown immunization status, deficient immunization (particularly Haemophilus influenzae type b and pneumococcus), or any pretreatment with antibiotics in the days preceding the seizure.\n\n**Disposition**\n\nTransfer to ICU occurs for status epilepticus, respiratory depression secondary to antiepileptic drugs, or persistent altered mental status. A video electroencephalogram monitoring unit is considered for concern about nonepileptic disorder mimicking seizures, ruling out subclinical seizures, or capturing events not witnessed by medical providers.\n\n**Discharge and Follow-up**\n\nDischarge occurs when baseline neurologic examination findings are restored. Primary care follow-up is arranged within 2 to 3 days and neurology follow-up within 1 to 2 weeks.\n\n**Safety Considerations**\n\nExcessive benzodiazepine use is monitored for, as it can cause respiratory failure." } ] }, { "article_id": 226, "article_title": "Sepsis", "sections": [ { "title": "Management", "content": "**Initial assessment and stabilization**\n\n1. [[178|Septic shock]] is recognised clinically: suspected infection with hypothermia or hyperthermia plus any of:\n - Decreased or [[142|altered mental status]]\n - Abnormal capillary refill time or pulse characteristics\n - Urine output <1 mL/kg/h\n - Note: hypotension is not required for diagnosis\n\n2. Blood cultures are obtained before antibiotics\n\n3. Specimens from non-blood sites (urine, cerebrospinal fluid, wound) are obtained for culture as soon as possible\n\n4. The first dose of antibiotics is administered without delay; every hour of delay beyond 3 hours incrementally increases harm\n\n**Respiratory support**\n\n- Supplemental oxygen is provided to all patients with sepsis to optimise oxygen delivery to tissues\n- Oxygenation is monitored with pulse oximetry\n- For sepsis-induced paediatric acute [[102|respiratory distress syndrome]], noninvasive mechanical ventilation (continuous positive airway pressure or biphasic positive airway pressure) is preferred\n- Intubation and mechanical ventilation are commonly used in children with [[178|septic shock]] in [[264|respiratory failure]] and in those with fluid-refractory, catecholamine-resistant septic shock without respiratory failure\n\n**Laboratory studies**\n\nAfter intravenous access is established, the following are obtained:\n- Complete blood count (may show leukocytosis or leukopenia)\n- Serum electrolytes\n- Rapid glucose measurement\n\n**Fluid resuscitation and further support**\n\n- Intravenous access is established\n- Initial fluid bolus is administered\n- Further support is determined by response to initial fluid resuscitation" } ] }, { "article_id": 227, "article_title": "Septic Arthritis", "sections": [ { "title": "Management", "content": "## Immediate Actions\n\n1. **Recognise the emergency**: Septic arthritis is a surgical and medical emergency requiring urgent intervention to prevent permanent disability.\n\n2. **Clinical assessment**:\n - Examine for joint swelling, erythema, warmth, and severe pain with movement\n - Assess ability to bear weight and range of motion\n - In hip involvement, look for flexed, externally rotated, abducted position\n - Take temperature and assess systemic signs\n\n3. **Urgent investigations**:\n - **Arthrocentesis** (ultrasound-guided if needed): obtain synovial fluid for Gram stain, culture, and cell count\n - Cell count >50,000/mL indicates septic arthritis\n - **Blood culture**\n - **Full blood count** (WBC)\n - **Inflammatory markers**: ESR and CRP\n - **Plain radiographs**: to identify effusion, [[175|osteomyelitis]], or subluxation\n - **Ultrasound**: to assess effusion and synovial thickening\n\n4. **Apply Modified Kocher criteria** to assess probability of septic arthritis:\n - Fever >38.5°C\n - Inability to bear weight\n - ESR >40 mm/h\n - WBC >12,000 cells/mL\n - CRP >20 mg/L\n\n## Antibiotic Therapy\n\n**Start empiric IV antibiotics immediately** pending culture results, even with negative Gram stain if clinical suspicion is high.\n\n**Choice depends on age and local resistance patterns:**\n\n- **Neonates and young infants (<2 months)**: Cover for group B streptococcus, *S. aureus*, and gram-negative enteric organisms\n - Example regimen: nafcillin with either gentamicin or cefotaxime\n\n- **Infants and children >2 months**: Target *S. aureus* as most common pathogen\n - Adjust based on local methicillin-resistant *S. aureus* prevalence\n\n**Duration**: Continue IV antibiotics for 6 weeks, adjusted according to culture sensitivity results.\n\n## Surgical Management\n\n**Urgent orthopaedic consultation required** for:\n- **Arthrocentesis for decompression**: performed both diagnostically and therapeutically\n- **Repeated aspiration**: if fluid reaccumulates\n- **Surgical drainage**: mandatory for septic arthritis of the hip or shoulder to prevent vascular compromise and ischemic necrosis of the femoral or humeral head\n- **Hip arthrotomy**: standard of care for hip involvement\n\n## Team Approach\n\nMultidisciplinary involvement essential:\n- Paediatrician\n- Paediatric orthopaedic surgeon\n- Microbiologist\n- Radiologist\n- Neonatologist (if neonatal case)\n\n**In resource-limited settings**: Urgent referral to tertiary centre where full team and treatment facilities are available." } ] }, { "article_id": 228, "article_title": "Speech Delay", "sections": [ { "title": "Clinical Approach", "content": "**Initial Assessment**\n\n1. **Developmental surveillance and screening** should be performed as part of routine primary pediatric care to identify children at risk for speech and [[378|language delay]].\n\n2. **Obtain detailed history** regarding:\n - Age of language milestones (babbling, first words, word combinations)\n - Any regression or loss of speech\n - Hearing concerns or recurrent ear infections\n - Global developmental delays in other domains\n - Family history of speech/language disorders or late language development\n - Environmental factors (stimulation, social interaction, abuse/neglect)\n - Do not accept rationalizations such as bilingual home, male sex, family history, or \"the child understands everything\" as explanations for delay\n\n3. **Assess comprehension of spoken language** to distinguish receptive from expressive delays.\n\n**Mandatory Referrals**\n\n- **Formal audiological examination** by an audiologist is essential for all children with suspected speech or [[378|language delay]]. This must not be performed in the pediatrician's office due to suboptimal conditions. Even mild [[248|hearing loss]] can cause language delays and may not be detected by newborn hearing screening.\n\n- **Autism-specific screening tool** (in conjunction with general developmental or language-specific screening) if [[117|autism spectrum disorder]] is suspected.\n\n- **Referral to developmental-behavioral pediatrician, neurodevelopmental pediatrician, or pediatric neurologist** if:\n - History of language regression\n - Delays in other developmental areas (up to 50% of children with [[378|language delay]] have delays elsewhere)\n - Suspected neurological disorder\n\n**Red Flags Requiring Urgent Evaluation**\n\n- Language regression (loss of previously acquired skills) suggests [[117|autism spectrum disorder]], Rett syndrome, or Landau-Kleffner syndrome and requires prompt specialist referral.\n\n**Counseling**\n\n- Inform families that approximately 60% of children with early language delays will catch up by 4 years of age, particularly with appropriate early intervention.\n- Emphasize that early intervention and early childhood special education services significantly improve outcomes.\n- Clarify that common concerns (birth order, bilingualism, television exposure) are not established causes of delay and should not delay evaluation." } ] }, { "article_id": 229, "article_title": "Substance Use Disorder", "sections": [ { "title": "Screening and Assessment", "content": "**Screening approach:**\n\nThe Substance Abuse and [[94|Mental Health]] Services Administration recommends universal screening for substance use as part of routine health care in all adolescents using the SBIRT (Screening Brief Intervention Referral and Treatment) system.\n\n**Diagnostic assessment:**\n\nDiagnosis is made primarily through clinical interview. In moderate to severe cases, examination for signs of toxidromes is performed on physical examination. The adolescent is assessed against the 11 DSM-5 criteria across four domains:\n\n1. **Impaired control:** consuming larger amounts than intended, persistent desire to cut down, spending significant time obtaining or using the substance, experiencing cravings\n2. **Social impairment:** failure to meet obligations at work/school/home, continued use despite interpersonal problems, reduction of important activities\n3. **Increased risk:** use in physically unsafe environments, continued use despite knowledge of harm\n4. **Pharmacologic features:** tolerance and withdrawal\n\nThe number of criteria met over the past 12 months is counted to determine severity.\n\n**Management by severity:**\n\n- **Mild SUD (2–3 criteria):** Can typically be managed in primary care with brief intervention and monitoring\n- **Moderate SUD (4–5 criteria):** Referral decision to subspecialty care is individualized based on clinical judgment\n- **Severe SUD (≥6 criteria):** Requires referral to specialized substance use treatment services\n\nWhen referring for specialty care, the primary care physician remains involved with the child and family, supporting their engagement with treatment, monitoring progress, and providing complementary primary care services." } ] }, { "article_id": 230, "article_title": "Systemic Lupus Erythematosus", "sections": [ { "title": "Management", "content": "The reference passages provided do not contain specific management protocols, drug doses, routes of administration, or per-kilogram dosing for the treatment of paediatric SLE. Therefore, detailed bedside management guidance cannot be provided from these sources.\n\nThe passages note that medications require explanation with awareness of potential side effects, and that the relationship between rheumatologist, patient, and family is important to overall improvement and well-being. Advice regarding pregnancy planning is mentioned as relevant for adolescent patients." } ] }, { "article_id": 231, "article_title": "Testicular Torsion", "sections": [ { "title": "Management", "content": "**Immediate assessment:**\n\n1. Focused history is obtained: acute onset (often nocturnal), severity of pain, presence of nausea/vomiting, abdominal or inguinal pain\n2. Testicular examination is performed on all boys presenting with abdominal pain\n3. TWIST score is calculated:\n - Testicular swelling: 2 points\n - Hard testis on palpation: 2 points\n - High-riding testis: 1 point\n - Absent cremasteric reflex: 1 point\n - Nausea or vomiting: 1 point\n\n**Risk stratification and next steps:**\n\n| TWIST Score | Risk | Action |\n|---|---|---|\n| 0 | Low | Imaging or close follow-up is considered |\n| 1–5 | Intermediate | Immediate colour Doppler ultrasound of scrotum |\n| 6–7 | High | Prompt surgical consultation without delay for imaging |\n\n**If high-risk or clinical diagnosis of testicular torsion is made:**\n\n- Immediate urological surgical consultation is obtained\n- Delay for imaging does not occur\n- If pain duration is <4–6 hours and surgical delay is anticipated, manual detorsion may be attempted:\n - The affected testis is rotated outward toward the thigh (medial-to-lateral direction)\n - Rotation is 180° at a time\n - Repetition occurs as needed (up to 4 attempts, as torsion may involve up to 720° rotation)\n - Successful detorsion produces dramatic pain relief\n- Prompt surgical detorsion with bilateral orchiopexy is arranged\n- If the patient is hospitalized, surgery should be performed before discharge\n\n**For intermittent torsion:**\n\n- Elective bilateral orchiopexy is arranged\n- Clear return precautions and close follow-up instructions are provided until surgery is performed" } ] }, { "article_id": 232, "article_title": "Viral Infection", "sections": [ { "title": "Management of Exposure", "content": "**Identification and Assessment**\n\nFollowing potential viral exposure in hospital or community settings:\n- All exposed individuals are identified (healthcare professionals, patients, visitors)\n- Immunity status is determined through clinical history or serological testing\n- Exposure timing and route are documented\n\n**Intervention**\n\nFor non-immune exposed individuals:\n- Varicella immunization is administered if no contraindications exist\n- VariZIG is administered up to day 10 postexposure for appropriate candidates\n- If VariZIG is unavailable, intravenous immunoglobulin (IGIV) is considered as an alternative\n\n**Monitoring**\n\nSymptom development is observed during the incubation period. Immunocompromised individuals require closer surveillance for disseminated disease and complications." } ] }, { "article_id": 233, "article_title": "Viral Upper Respiratory Infection", "sections": [ { "title": "Management", "content": "**Assessment**\n\nObtain a clinical history focusing on symptom onset, fever pattern, nasal discharge character, cough timing, and systemic symptoms. Examine for signs of systemic illness, respiratory distress, and otoscopic findings.\n\n**Diagnosis**\n\nViral URI is primarily a clinical diagnosis. Diagnostic testing is not routinely indicated for uncomplicated cases. In children with cystic fibrosis presenting with new respiratory symptoms, obtain a chest X-ray and compare with prior studies to assess for pulmonary exacerbation.\n\n**Treatment**\n\nManagement is supportive and symptomatic. No specific antiviral therapy is indicated for most children with uncomplicated viral URI. Treatment focuses on:\n\n- Symptomatic relief measures\n- Monitoring for resolution within 7–10 days\n- Reassurance that clear nasal discharge, cough peaking on days 3–6, and low-grade fever are expected\n\n**Special Considerations**\n\nIn children with cystic fibrosis, viral URIs do not automatically require antimicrobial treatment. However, if signs of acute pulmonary exacerbation develop, contact the CF centre to discuss antimicrobial therapy criteria and optimal antibiotic selection based on previous airway culture results.\n\n**Red Flags for Bacterial Superinfection**\n\nRefer for further evaluation if:\n- Fever persists or recurs on days 6–7 at ≥39°C\n- Nasal discharge or cough worsens after initial improvement\n- Symptoms persist beyond 10 days without improvement\n- Signs of severe illness or complications develop" } ] }, { "article_id": 234, "article_title": "Vitamin B12 Deficiency", "sections": [ { "title": "Management", "content": "**Diagnosis and confirmation**\n\n1. Serum vitamin B12 level is measured\n2. If B12 is normal or low-normal but clinical suspicion remains high, ancillary testing is obtained: methylmalonic acid and homocysteine levels\n3. MRI of cervical spine is considered if neurologic signs are present (T2 hyperintensity in dorsal columns is sought)\n\n**Treatment initiation**\n\nVitamin B12 is administered by intramuscular injection:\n\n- **Initial phase**: Daily doses of 25–100 μg intramuscularly\n- **Maintenance phase**: Monthly intramuscular injections of 200–1,000 μg\n\n**Special dosing**\n\nFor complete transcobalamin II deficiency: 1,000 μg intramuscularly two or three times weekly, maintaining very high serum cobalamin levels\n\n**Duration**\n\nMost cases of vitamin B12 deficiency require treatment throughout life. Rapid clinical improvement is expected with replacement therapy, though the duration of prior deficiency influences the likelihood of permanent neurologic sequelae." } ] }, { "article_id": 235, "article_title": "Abdominal Mass", "sections": [ { "title": "Clinical evaluation and management", "content": "**Physical examination**\n\nPerform careful, gentle palpation of the abdomen after allowing the child to calm. Limit palpation to as few examiners as possible, as masses may be fragile and prone to rupture. Attempt to define mass location, size, consistency, and mobility. In males, examine for left-sided varicocele (associated with Wilms tumour). In females with lower abdominal mass, assess for imperforate hymen.\n\n**Imaging sequence**\n\n1. **Plain abdominal radiograph** — first-line to confirm mass presence and exclude acute obstruction or perforation\n2. **Ultrasonography** — mainstay of initial diagnosis during hospitalisation\n3. **CT with contrast material** — if malignancy, teratoma, focal hepatic lesion, or infection/abscess suspected; include pelvic and chest imaging if malignancy suspected\n4. **MRI with and without contrast** — for hepatobiliary masses or suspected Kasabach-Merritt syndrome (note: may require sedation or anaesthesia)\n\n**Laboratory workup**\n\nOrder baseline tests for all patients:\n- Complete blood count with differential\n- Electrolytes (including calcium and phosphorus), BUN, creatinine\n- Uric acid, lactate dehydrogenase\n- Urinalysis\n- Urine homovanillic acid and vanillylmandelic acid\n- Serum beta-human chorionic gonadotropin and alpha-fetoprotein\n\nAdd organ-specific tests based on imaging findings:\n\n| Organ | Additional tests |\n|-------|------------------|\n| Liver | Liver function tests (ALT, AST, GGT, albumin, total and direct bilirubin), PT/PTT |\n| Kidney/adrenal | Urinalysis, urine HVA/VMA |\n| Ovary | AFP, quantitative beta-HCG |\n| Pancreas | Amylase, lipase |\n\n**Disposition**\n\nInitial hospitalisation is focused on diagnostic evaluation. Arrange specialist consultation based on suspected diagnosis. Treatment decisions follow once diagnosis is established." } ] }, { "article_id": 236, "article_title": "Alcohol Intoxication", "sections": [ { "title": "Management at the Bedside", "content": "**Initial assessment:**\n- Blood alcohol concentration is obtained\n- Airway, breathing, and circulation are assessed\n- Secondary survey for traumatic injury is performed ([[139|head trauma]] commonly accompanies intoxication)\n- Blood glucose is checked immediately\n\n**Mild intoxication (BAC <100 mg/dL):**\n- Close observation\n- Hydration is provided\n- Analgesics are administered as needed\n\n**Moderate to severe intoxication (BAC >300 mg/dL):**\n- Airway management is established\n- Artificial ventilatory support is provided (respiratory [[204|depression]] is the primary cause of death)\n- Supportive care is initiated\n\n**Hypoglycaemia management:**\n- If blood glucose <60 mg/dL: IV infusion of D5W or D10W is started\n\n**Seizures:**\n- Treated with diazepam or phenytoin\n\n**Severe withdrawal symptoms:**\n- Benzodiazepines are considered\n\n**Acute psychosis:**\n- Managed with haloperidol\n\n**Severe cases:**\n- Cerebral oedema is monitored for and treated appropriately\n\n**Dialysis consideration:**\n- Considered when BAC >400 mg/dL\n\n**Disposition:**\n- Following acute stabilization, referral is made for alcohol use disorder treatment (group counselling, individualized counselling, or multifamily educational intervention)" } ] }, { "article_id": 237, "article_title": "Bacterial Gastroenteritis", "sections": [ { "title": "Management", "content": "**Assessment and Initial Management**\n\nDehydration and shock are rapidly assessed, particularly in infants who can deteriorate quickly. Hypoglycemia, which is common in young infants, is checked for. A history of bloody diarrhea (suggests bacterial infection) and recent antibiotic use (suggests *C. difficile*) is obtained.\n\n**Fluid Resuscitation**\n\nFluid resuscitation is the cornerstone of treatment. In infants, this may improve clinical appearance and clarify whether dehydration is the primary diagnosis.\n\n**Diagnostic Testing**\n\nStool culture is sent for bacterial identification (results in several days). Rapid PCR detection of gastrointestinal pathogens is considered if available. Complete blood count is obtained; bandemia with normal WBC count suggests *Shigella*. For suspected *Vibrio* infection, the laboratory is notified so special identification techniques can be employed.\n\n**Antibiotic Treatment**\n\nAntibiotics are indicated for:\n- *Salmonella* (nontyphi): Ceftriaxone or azithromycin if bacteremic, <3 months old, or immunocompromised (including children with hemoglobinopathies)\n- *Shigella*: Azithromycin or ceftriaxone daily for 3 days\n- *Giardia*: Metronidazole 15 mg/kg/day divided into three daily doses for 5 days (maximum 750 mg/day)\n\nFor invasive disease from susceptible strains, an expanded-spectrum cephalosporin, azithromycin, or fluoroquinolone is used.\n\n**Monitoring and Disposition**\n\nTransfer to ICU is indicated for decompensated shock unresponsive to fluid boluses, concern for acute adrenal insufficiency, [[241|diabetic ketoacidosis]], increased intracranial pressure, or [[100|myocarditis]].\n\nDischarge is appropriate when dehydration has resolved, oral intake is adequate to maintain hydration, and oral antibiotics (if indicated) are tolerated.\n\n**Specialist Consultation**\n\n- **Gastroenterology**: Persistent diarrhea >14 days, significant GI bleeding, or suspected [[254|inflammatory bowel disease]]\n- **Infectious disease**: Unusual or resistant pathogen, multiple *C. difficile* recurrences\n- **Surgery**: Possible [[193|acute abdomen]]" } ] }, { "article_id": 238, "article_title": "Bacterial Meningitis", "sections": [ { "title": "Management", "content": "**Immediate Actions**\n\n1. **The clinical picture is recognised**: Fever with irritability, vomiting, altered sleep, or paradoxical irritability (worsens with handling). Bulging fontanelle in infants. [[315|Seizures]] in 20% of cases.\n\n2. **Neuroimaging before lumbar puncture is decided upon**: CT scan is performed prior to lumbar puncture if the child has coma, recent CNS trauma, focal neurological deficit, papilledema, or cerebrospinal fluid shunt. Neuroimaging is also considered in immunocompromised children.\n\n3. **Antibiotics are started immediately** (lumbar puncture results are not awaited):\n - **Vancomycin**: 60 mg/kg intravenously\n - **Ceftriaxone**: 100 mg/kg intravenously, up to 2 g, every 12 hours\n\n4. **Lumbar puncture is performed** (once safe to do so) and cerebrospinal fluid is sent for:\n - Gram stain\n - Culture and sensitivities\n - Cell count with differential\n - Protein\n - Glucose\n - Opening pressure measurement\n\n5. **Cerebrospinal fluid findings are interpreted**:\n - WBC count typically >1,000/μL with neutrophil predominance\n - Glucose <40 mg/dL\n - Protein >100 mg/dL\n - Opening pressure may be >25 cm H₂O in older children\n - Absence of organism on Gram stain does not exclude bacterial [[147|meningitis]]\n\n**Ongoing Management**\n\n6. **Antibiotics are adjusted based on susceptibilities** once available:\n - For susceptible organisms: aqueous penicillin G 250,000 U/kg per day divided every 4 hours OR ampicillin 300 mg/kg per day divided every 6 hours\n - For penicillin- and cephalosporin-resistant *S. pneumoniae*: vancomycin and ceftriaxone are continued; rifampin may be added\n\n7. **Adjunctive dexamethasone is added**:\n - Dose: 0.15 mg/kg per dose intravenously\n - Frequency: every 6 hours\n - Duration: 2 days\n - Timing: begins with the first dose of antibiotic\n - Benefit: reduces [[248|hearing loss]] and short-term neurological sequelae\n\n8. **Antibiotic therapy is continued**:\n - Neonates: 3 weeks\n - Older children: 7–10 days (may extend longer)\n\n9. **Infection control**:\n - Droplet precautions for meningococcal [[147|meningitis]]\n - Standard precautions for other bacterial causes\n\n10. **Supportive care**: Raised intracranial pressure, electrolyte imbalances, and [[315|seizures]] are managed as needed. Intensive care unit admission is considered for close initial monitoring." } ] }, { "article_id": 239, "article_title": "Bacterial Vaginosis", "sections": [ { "title": "Management", "content": "**Diagnosis**\n\nApply Amsel criteria: diagnose BV if ≥3 of the following are present:\n1. Homogenous, thin, grey or white vaginal discharge\n2. Vaginal pH >4.5 (do not use if blood is present)\n3. Positive whiff-amine test: add 10% potassium hydroxide to discharge sample and observe for fishy odor\n4. Clue cells on wet mount: mix vaginal fluid with saline and examine microscopically for epithelial cells with adherent bacteria\n\n**Treatment**\n\nChoose one of the following regimens:\n\n| Option | Dose | Route | Duration |\n|--------|------|-------|----------|\n| Metronidazole | 500 mg | Orally, twice daily | 7 days |\n| Metronidazole gel 0.75% | 5 g | Intravaginally, daily | 5 days |\n| Clindamycin cream 2% | 5 g | Intravaginally, daily | 7 days |\n| Metronidazole | 2 g | Orally, single dose | Once |\n| Tinidazole | 2 g | Orally, single dose | Once |" } ] }, { "article_id": 240, "article_title": "Brain Death", "sections": [ { "title": "Clinical Assessment and Documentation", "content": "**Step 1: Verify Prerequisites**\n\nBefore the brain death examination begins, the following prerequisites are confirmed:\n- Known catastrophic brain injury from recognised aetiology ([[272|traumatic brain injury]], anoxic brain injury, intracranial infection, [[338|toxic ingestion]], or other specified cause)\n- Blood pressure normal for age\n- Core temperature >35°C\n- Serum electrolytes normal\n- Blood glucose normal\n- No sedating medications or muscle relaxants on board\n- Sufficient time elapsed for clearance of any sedating drugs or toxins\n- Reversible causes of coma excluded through review of medical history, neuroimaging, EEG, and laboratory data\n\n**Step 2: First Clinical Examination**\n\nA comprehensive neurologic examination is performed, documenting:\n- Deep coma: unresponsiveness to tactile, auditory, and visual stimulation (excluding spinally mediated reflexes)\n- Absent brainstem reflexes: all cranial nerve reflexes are tested as per institutional protocol\n- Apnea: absence of respiratory effort with adequate respiratory stimulus\n- Any motor movements are confirmed as spinally mediated; ancillary testing is used if the distinction is unclear\n\n**Step 3: Observation Period**\n\n- Term newborns (37 weeks gestational age) to 30 days old: at least 24 hours are observed before the second examination\n- Children 31 days to 18 years old: at least 12 hours are observed before the second examination\n- The observation interval may be shortened if an ancillary study (EEG or other) is consistent with brain death\n\n**Step 4: Second Clinical Examination**\n\nThe complete neurologic examination is repeated, with the same findings as the first examination.\n\n**Step 5: Documentation**\n\nThe institutional brain death checklist is used to document:\n- Irreversible and identifiable cause of coma\n- Correction of confounding conditions\n- Completion of all components of neurologic examination\n- Timing of both examinations and observation interval\n- Results of any ancillary testing performed\n- Names and credentials of examining physicians\n\n**Note on Ancillary Testing**\n\nAncillary tests such as EEG may be used if the patient cannot tolerate portions of the clinical examination (particularly apnea testing) or is very young, especially under 1 year of age." } ] }, { "article_id": 241, "article_title": "Diabetic Ketoacidosis", "sections": [ { "title": "Management", "content": "**Initial Assessment and Investigations**\n\n1. [[124|Pediatric endocrinology]] and/or pediatric intensive care is consulted early\n2. Height and weight are obtained (compared to premorbid weight)\n3. Severity of [[99|dehydration]] and level of consciousness are assessed\n4. Essential investigations are performed:\n - Blood glucose\n - Blood ketones\n - Urea and electrolytes, creatinine\n - Blood gas analysis\n - Blood and urine cultures (to identify infection)\n - Cardiac monitor (assess for T-wave changes of hypokalaemia)\n\n**Treatment Goals**\n\n- Circulating volume is restored\n- Metabolic derangements are corrected\n- Treatment complications (hypokalemia, cerebral edema) are avoided\n- The underlying cause (infection, insulin pump malfunction, etc.) is identified and treated\n\n**Monitoring for Complications**\n\nCerebral edema, which typically presents 4–12 hours after treatment initiation, is watched for. High vigilance is maintained in patients with risk factors: elevated blood urea nitrogen, low CO₂ tension, age under 3 years, new-onset diabetes, or failure of serum sodium to rise steadily during hyperglycemia correction." } ] }, { "article_id": 242, "article_title": "Duchenne Muscular Dystrophy", "sections": [ { "title": "Management", "content": "**Diagnosis**\n\n1. Serum creatine kinase level is obtained (marked elevation, 10–10,000 times normal, is expected)\n2. Genetic testing is performed on peripheral blood (detects mutations in ~70% of cases)\n3. If genetic testing is negative, muscle biopsy with dystrophin analysis is arranged\n4. Intellectual function is assessed and screening is performed for [[114|learning disability]], ADHD, and [[117|autism spectrum disorder]]\n\n**Pharmacological Management**\n\nSystemic corticosteroids are indicated to slow disease progression and maintain strength. Specific dosing regimens are not detailed in the available passages.\n\n**Monitoring and Complications**\n\n- Respiratory complications after loss of ambulation, including [[224|scoliosis]], ineffective cough, and sleep-disordered breathing, are monitored for\n- Cardiac function is assessed regularly given the high incidence of cardiomyopathy and dysrhythmias\n- Diaphragm function is evaluated, as weakness is common\n- Multidisciplinary care is provided, addressing neuromuscular, respiratory, cardiac, orthopedic, endocrine, gastrointestinal, and nutritional needs\n- Psychosocial support and transition planning are coordinated across the lifespan" } ] }, { "article_id": 243, "article_title": "Dyslexia", "sections": [ { "title": "Assessment and Management", "content": "**Initial Recognition and Referral**\n\nSuspect dyslexia in children presenting with unexpected reading difficulty despite normal intelligence. Early identification is critical: kindergarten assessments of language skills (rhyming, letter naming) can identify at-risk children before reading instruction begins.\n\n**Diagnostic Evaluation**\n\n1. **Exclude sensory and systemic causes**: Arrange vision and hearing assessment to rule out concurrent ocular or auditory problems\n2. **Refer to educational psychologist** for comprehensive assessment including:\n - Tests of language, particularly phonology\n - Reading tests (real and pseudowords)\n - Reading fluency assessment\n - Spelling tests\n - Intellectual ability testing\n - Additional testing of memory, general language skills, and mathematics as indicated\n3. **Occupational therapist and speech/language therapist** may provide additional assessment when needed\n\n**Diagnosis**\n\nDyslexia is diagnosed by demonstrating a significant discrepancy between reading ability and intelligence, with reading achievement more than 2 years behind chronological age. The phonological deficit should be circumscribed and not extend into other cognitive domains.\n\n**Management**\n\nOnce diagnosed, refer for evidence-based intervention directed at the phonological deficit:\n- Daily intensive individualized instruction\n- Explicit teaching of phonemic awareness\n- Systematic phonics instruction\n- Reading fluency training\n- Vocabulary and comprehension instruction\n\n**Comorbidity Screening**\n\nAssess for [[111|attention-deficit/hyperactivity disorder]], which coexists in a significant proportion of dyslexic children. Manage comorbid conditions concurrently with dyslexia intervention." } ] } ]