[
  {
    "article_id": 198,
    "article_title": "Bronchopulmonary Dysplasia",
    "section_id": "d7e38fdb090f4b5c9c13d7ca79f3bbf1",
    "section_title": "Management Approach",
    "variant": "clinical",
    "imperatives": 6,
    "content": "**Initial Assessment and Monitoring**\n\nIdentify risk in premature infants on mechanical ventilation or supplemental oxygen beyond 10–14 days. Assess severity 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\nPrescribe supplemental oxygen 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 should be the goal for all preterm babies requiring mechanical ventilation. Use gentle ventilation strategies and early, aggressive continuous positive airway pressure (CPAP) to reduce barotrauma.\n\n**Preventive Pharmacotherapy**\n\nAdminister antenatal steroids prenatally when possible. Provide early surfactant therapy. Consider early caffeine therapy. Reserve systemic steroids for selective cases only.\n\n**Supportive Care**\n\nOptimize nutrition to support growth. Provide early stimulation. Address parental anxiety. Screen for and manage associated conditions including [[245|gastroesophageal reflux]] and [[259|patent ductus arteriosus]].\n\n**Monitoring for Complications**\n\nPerform echocardiography to assess for pulmonary hypertension in established BPD. Monitor for signs of chronic respiratory insufficiency and cor pulmonale. Anticipate high rehospitalization risk in the first 2 years of life."
  },
  {
    "article_id": 200,
    "article_title": "Concussion",
    "section_id": "5e97071a57ec446783778e7d35e4550e",
    "section_title": "In short",
    "variant": "short",
    "imperatives": 1,
    "content": "- Concussion is [[272|traumatic brain injury]] from acceleration, deceleration, or rotational forces; loss of consciousness is not required\n- Causes metabolic and vascular changes in brain tissue, not structural damage on standard imaging\n- Common symptoms include confusion, headache, visual disturbance, amnesia, balance problems, dizziness, nausea, and cognitive/behavioral changes\n- Most sport-related concussions resolve within 7–10 days, but some develop persistent symptoms beyond 28 days\n- Diagnosis uses SCAT3, Child-SCAT3 (ages 5–12), or Acute Concussion Evaluation (ACE)\n- CT imaging is rarely needed beyond 24 hours unless patient has [[142|altered mental status]], prolonged unconsciousness, repeated vomiting, severe headache, skull fracture signs, focal neurologic deficit, or severe mechanism\n- Immediate removal from play is mandatory; athlete cannot return to sport on day of injury\n- Management includes rest (including cognitive rest) and gradual return-to-activity progression\n- Refer to concussion specialist if symptoms persist beyond 10–14 days, worsen, or patient has multiple prior concussions\n- Second impact syndrome (rare but potentially fatal) occurs with second concussion while symptomatic from first"
  },
  {
    "article_id": 200,
    "article_title": "Concussion",
    "section_id": "01efcfd3ae074e5e9dae90a9066f481f",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 7,
    "content": "**Immediate Assessment and Safety**\n\n- Remove any athlete suspected of concussion from play immediately\n- Do not permit return to sport on the day of injury\n- Do not leave the athlete alone in the initial hours; monitor for deterioration\n\n**Diagnostic Evaluation**\n\n- Use the Acute Concussion Evaluation (ACE) in clinic or emergency department settings\n- Apply Child-SCAT3 for children aged 5–12 years or SCAT3 for older athletes\n- Obtain computed tomography 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- Encourage rest, including cognitive rest\n- Provide the ACE Care Plan to parents and child for guidance\n- Implement strict return-to-activity guidelines with gradual increase in both physical and mental activities\n\n**Follow-up and Specialist Referral**\n\n- Refer to a concussion specialist if:\n  - Symptoms persist beyond 10–14 days\n  - Symptoms worsen\n  - Patient has a history of multiple concussions"
  },
  {
    "article_id": 201,
    "article_title": "Constipation",
    "section_id": "0169043983484fefb09c04c671e32d1f",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Initial Assessment**\n\n1. Take a detailed history of stool frequency, consistency, and difficulty; pain or straining; and recent stressors or dietary changes\n2. Perform physical examination including abdominal palpation and assessment of anal tone\n3. Obtain stool sample for occult blood testing (note: false positives occur after rare red meat or peroxidase-containing vegetables)\n4. Assess for fecal leukocytes (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), consider:\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, perform:\n- Sweat test or genetic testing for [[184|cystic fibrosis]]\n\n**Treatment of [[289|Functional Constipation]]**\n\nImplement three-pronged management:\n\n| Component | Intervention |\n|-----------|-------------|\n| **Behaviour** | Establish regular toileting practices; address family dynamics and parental response; manage stool-withholding behaviour |\n| **Diet** | Decrease: simple carbohydrates, refined/processed carbohydrates, saturated fat, processed meat, dairy (milk and cheese). Increase: fluid intake and dietary bulk |\n| **Medication** | Perform initial 'clean out' of retained stool, then maintain with stool softeners and agents to propel stool through colon |\n\n**When to Investigate Further**\n\nIf inadequate response to presumptive treatment with education, dietary changes, and medication, or if concern for organic aetiology exists, proceed with further investigation."
  },
  {
    "article_id": 202,
    "article_title": "Corneal Abrasion",
    "section_id": "74c3c2d81cc240f699b377658c7f3399",
    "section_title": "In short",
    "variant": "short",
    "imperatives": 1,
    "content": "- Corneal abrasion is loss of the superficial epithelial layer, exposing underlying nerves and causing severe pain, tearing, and photophobia\n- Most common ocular injury of childhood; contact lens wearers at increased risk\n- Typical mechanism is accidental trauma during play, sports, or self-inflicted scratching in infants\n- Diagnosis: fluorescein dye under blue light (cobalt blue, Wood lamp, or slit lamp blue filter) shows bright yellow-green staining; abrasion appears transparent without dye\n- Always evert eyelids to check for retained foreign bodies, particularly under upper lid\n- Treat with frequent topical antibiotic ointment until healed; use oral analgesia for pain\n- Topical anesthetics only for examination—do not send home as they slow healing and inhibit blinking\n- Contact lens wearers need topical fluoroquinolones to cover Pseudomonas\n- Semipressure patching does not improve healing and may cause further abrasion\n- Complications include corneal scarring and vision loss if infection develops"
  },
  {
    "article_id": 202,
    "article_title": "Corneal Abrasion",
    "section_id": "5991076f73e34866ac03d76eff398a3c",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Examination and Diagnosis**\n\n1. Instil topical anesthetic drops (proparacaine 0.5%) to facilitate examination and provide temporary pain relief\n2. Instil fluorescein dye using either:\n   - Dry impregnated strip (preferred): wet with water, normal saline, or Ringer's solution, then gently touch to pink palpebral conjunctiva of lower lid or bulbar conjunctiva\n   - Liquid drop form\n3. Examine under blue-filtered light (cobalt blue on direct ophthalmoscope, slit lamp, or Wood lamp)\n4. Evert upper eyelid to inspect for foreign bodies\n5. Retract lower eyelid to inspect inferior conjunctiva\n6. Perform vision testing\n\n**Treatment**\n\n1. **Topical antibiotic ointment**: Apply frequently until epithelium is completely healed\n   - For contact lens wearers: use topical fluoroquinolones to cover Pseudomonas species\n\n2. **Oral analgesia**: Initiate in all cases for pain control\n\n3. **Topical cycloplegic agent** (for large abrasions): Cyclopentolate hydrochloride 1% to relieve pain from ciliary spasm\n\n4. **Foreign body removal** (if present):\n   - Superficial foreign bodies: remove with moist cotton-tipped applicator\n   - Deeper foreign bodies: refer to ophthalmologist\n\n**Important Notes**\n\n- Do NOT send patient home with topical anesthetic drops—they retard epithelial healing and inhibit blinking reflex\n- Do NOT use semipressure patch—does not improve healing time or decrease pain, and may itself cause abrasion\n- Refer to ophthalmologist if vision changes are present or if deeper foreign body suspected"
  },
  {
    "article_id": 203,
    "article_title": "Cyclic Vomiting Syndrome",
    "section_id": "0265f7928b6e4ad39a27ed2044402c46",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Initial Assessment**\n\n1. Confirm the pattern: obtain history of episode frequency, duration, timing of onset, and intervening symptom-free periods\n2. Assess for warning signs requiring urgent investigation:\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 present: add liver and pancreatic function tests, abdominal imaging (ultrasound ± CT/MRI), consider oesophagogastroduodenoscopy\n- If metabolic triggers suspected (fasting, high-protein meals, intercurrent illness): serum and urine metabolic panel (lactate, ammonia, carnitine profile, amino acids, organic acids) **prior to IV fluid treatment**\n- If neurological abnormalities: brain MRI and neurology consultation\n\n**Acute Episode Management**\n\n**Prodromal phase (if recognised):**\n- Administer 5HT3 antagonist antiemetic:\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 if needed: lorazepam\n- Analgesia as necessary for pain\n- Monitor serum urea and electrolytes during treatment\n\n**Expected course:** Episodes typically resolve within 24–48 hours with supportive care."
  },
  {
    "article_id": 204,
    "article_title": "Depression",
    "section_id": "969d710845684aa7b8c77ec8c6b02780",
    "section_title": "Assessment and management",
    "variant": "clinical",
    "imperatives": 6,
    "content": "**Initial evaluation**\n\n1. Obtain detailed clinical history including mood, functioning, and change from baseline\n2. Perform mental status examination\n3. Screen for suicidal ideation and self-harm risk\n4. Assess for psychotic features by asking directly: \"Do you ever feel your eyes or ears play tricks on you?\"\n5. Take family history of depression, anxiety, and suicide\n6. Identify environmental stressors and adverse childhood experiences\n7. Screen for comorbid anxiety, ADHD, [[286|conduct disorder]], and chronic medical conditions\n8. Use validated screening tool as adjunct (PHQ-9: Modified for Teens, Beck Depression Inventory, or Children's Depression Inventory)\n\n**Referral for definitive diagnosis**\n\nRefer to 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 should be determined by the psychiatrist.\n\n**Psychoeducation for family**\n\n- Explain that depression is common and not due to lack of coping ability or personal strength\n- Discuss family history to reduce stigma\n- Clarify that symptoms are real, not fabricated\n- Explain that apparent laziness or irritability are symptoms, not character flaws\n- Emphasise that hopelessness is a symptom, not reality\n- Reassure that treatment works, though improvement takes several weeks\n- Note that the affected individual is often the last to recognise improvement"
  },
  {
    "article_id": 205,
    "article_title": "Drug Reaction",
    "section_id": "f6a9e97563be4113a3f023aa92ae14fe",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Immediate assessment:**\n- Identify the temporal relationship between drug exposure and symptom onset\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- Discontinue the offending drug immediately\n- Provide supportive care and airway management as needed\n\n**For DRESS:**\n- **Primary intervention:** Discontinue the offending drug immediately\n- Avoid similar cross-reacting drugs\n- Provide supportive care\n- Consider systemic glucocorticoids (evidence is limited but believed effective)\n- Monitor for persistent or worsening symptoms, which may continue for weeks to months after drug withdrawal\n- Assess for multiorgan involvement, particularly hepatic and renal function\n\n**For other cutaneous drug reactions:**\n- Discontinue the offending drug\n- Most reactions confined to the skin resolve without sequelae after drug withdrawal\n- Provide supportive care"
  },
  {
    "article_id": 206,
    "article_title": "Epilepsy",
    "section_id": "79e9bd05ad5b44c7a088806619d48fb2",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "### Initial Assessment\n\nWhen a child presents with a first seizure, establish whether it was provoked or unprovoked. Obtain a detailed history of the event, including duration, type of movements, consciousness level, and postictal state. Perform neurological examination and consider EEG 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\nPerform interictal EEG 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",
    "section_id": "5d06186510f54e8d82d5c481f2907a79",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Assessment**\n\nErythema toxicum neonatorum is a clinical diagnosis. Examine the rash distribution, morphology, and timing of onset. Confirm the diagnosis 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. Reassure parents that the rash is benign and self-limited.\n\n**Monitoring**\n\nNo specific follow-up is necessary. Lesions will resolve without intervention, scarring, or pigmentation changes."
  },
  {
    "article_id": 210,
    "article_title": "Herpes Simplex Virus Infection",
    "section_id": "ef2515315c9f4d9494c93c41afb1e123",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Assessment and diagnosis**\n\nIdentify clinical presentation: vesicular lesions on erythematous base (typically grouped), oral ulceration (gingivostomatitis), or systemic symptoms. In neonates, determine timing of presentation (5–14 days suggests localised SEM disease; 14–28 days suggests CNS involvement). Obtain maternal history of genital herpes and immunity status where possible.\n\n**Risk stratification**\n\nIdentify high-risk groups requiring urgent evaluation and treatment:\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; refer to current formulary guidance for age-appropriate and weight-based dosing.\n\nFor neonates and immunocompromised children with suspected or confirmed HSV infection, aciclovir should be initiated promptly given the risk of severe or life-threatening disseminated disease.\n\n**Supportive care**\n\nManage pain and fever 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",
    "section_id": "c8b4c3f243dd4a2ba782f63eec1f0fa1",
    "section_title": "Bedside Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Immediate steps:**\n\n1. **Airway and breathing:** Ensure airway is open and clear; consider intubation if needed. Administer oxygen via nonrebreather mask at 10–15 L/min.\n\n2. **Position:** If hypotensive, place child in Trendelenburg position (unless breathing is compromised). If stable, allow child to remain in position of comfort with caregiver.\n\n3. **Vascular access:** Establish intravenous or intraosseous access.\n\n4. **Initial fluid bolus:** Give isotonic crystalloid (0.9% sodium chloride or lactated Ringer's solution) at **20 mL/kg body weight** (maximum 1 L bolus) over 5–10 minutes.\n\n5. **Reassess:** Check perfusion (pulses, capillary refill, skin temperature, urine output, mental status).\n\n**Repeat boluses:** If perfusion has not normalized, repeat the 20 mL/kg bolus. 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, transfuse packed red blood cells. 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:** Place emergency umbilical catheter and give volume expansion 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": 211,
    "article_title": "Hypovolemic Shock",
    "section_id": "a9ee162405b1450fb2ca3944b8229ce2",
    "section_title": "Treatment and Management",
    "variant": "long",
    "imperatives": 2,
    "content": "**Initial approach:** Ensure the airway is open, clear, and maintained; consider intubation if needed. Administer oxygen via nonrebreather mask at 10–15 L/min to optimize arterial oxygen content. Position the child in Trendelenburg position if hypotensive, unless breathing is compromised; otherwise allow the child to remain in a position of comfort with a caregiver.\n\n**Fluid resuscitation:** Isotonic crystalloid solutions (normal saline or lactated Ringer's solution) are as effective as colloid solutions for most patients. Give an initial bolus of 20 mL/kg body weight (maximum 1 L) and repeat as necessary until perfusion normalizes. In nonhemorrhagic hypovolemic shock, up to 40 mL/kg may be needed before the child responds; typically no more than 60 mL/kg is required, though more may be necessary if ongoing losses are severe.\n\n**Blood transfusion:** In trauma patients who do not respond to initial crystalloid bolus, packed red blood cell transfusion is indicated, though the specific volume required is not well established.\n\n**Pressors:** Not required in simple hypovolemic states.\n\n**Prehospital care:** Prevent further injury, immobilize the cervical spine if trauma is suspected, and splint fractures. Transport rapidly to hospital. For [[273|acute gastroenteritis]] with dehydration, start oral rehydration solution at home and during transport."
  },
  {
    "article_id": 212,
    "article_title": "Intellectual Disability",
    "section_id": "385076335f5d47e897fb2287521d3835",
    "section_title": "Assessment and Diagnosis",
    "variant": "clinical",
    "imperatives": 8,
    "content": "**Initial evaluation:**\n\n1. Obtain detailed developmental history including pregnancy, birth history, and achievement of [[10|developmental milestones]] across motor, cognitive, language, and social domains\n2. Obtain detailed family history and assess for familial or reproductive history suggestive of chromosomal rearrangements\n3. Perform complete physical examination, evaluating specifically for dysmorphic features and [[115|congenital anomalies]]\n4. Review newborn screening results\n\n**Cognitive and adaptive assessment:**\n\n- Administer standardized intelligence testing (generally possible at age 3–4 years or older)\n- Assess adaptive behavior across conceptual, social, and practical domains\n- Document that deficits manifest during the developmental period and cause functional impairment\n\n**Diagnostic considerations:**\n\n- Account for cultural, linguistic, sensory, motor, and behavioral factors that may affect assessment\n- In children younger than 5 years with delays in two or more developmental domains, use the term \"global [[82|developmental delay]]\" rather than intellectual disability\n- Recognize that diagnosis can be 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- Consider whole exome sequencing for cases with features suggesting a specific genetic diagnosis\n\n**Early intervention:**\n\n- Refer infants and young children with delayed cognitive development to early intervention programs to increase the probability of functional improvements over time"
  },
  {
    "article_id": 212,
    "article_title": "Intellectual Disability",
    "section_id": "65d02b5faabb41a58ea19b41cfd695ee",
    "section_title": "Support and Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Educational and functional planning:**\n\n- Develop individualized education programs (IEP) or individualized family service plans (IFSP) as appropriate\n- Recognize that limitations often coexist with strengths; supports should be determined based on identified limitations\n- Implement supports across multiple settings (home, school, community) rather than restricting them to structured environments\n\n**Communication support:**\n\n- Assess need for augmentative and alternative communication (AAC) supports\n- Recognize that AAC use can be beneficial for at least 30% of school-age individuals requiring such supports\n- Generalize AAC use across all settings to maximize functional communication\n\n**Inclusive environment:**\n\n- Facilitate participation in inclusive environments typical of same-age peers\n- Provide appropriate supports to enable individuals to live and learn successfully in community settings\n- Recognize that individuals with intellectual disability can gain functional skills over time with appropriate support systems in place"
  },
  {
    "article_id": 213,
    "article_title": "Long Qt Syndrome",
    "section_id": "43eae9079e9d4abbb39f17f9dced4f9b",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Initial Evaluation**\n\nSuspect long QT syndrome 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\nObtain a resting 12-lead ECG immediately. Measure the QT interval and calculate the corrected QT interval (QTc) using the Bazett formula: QTc = QT/√(RR interval).\n\nInterpret 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 but note 25% false negative rate\n\n**Electrolyte Assessment**\n\nIn any patient with QT prolongation, measure serum potassium, calcium, and magnesium to exclude acquired causes. Correct any deficiencies.\n\n**Family Screening**\n\nPerform ECG on first-degree relatives. Genetic testing should be offered to family members of confirmed cases.\n\n**Treatment Principles**\n\nTreat asymptomatic patients with a prolonged QT interval and positive family history to prevent sudden death. Management is individualised based on genetic subtype and symptom triggers. Avoid medications known to prolong QT interval (class Ia and III antiarrhythmics, azithromycin, and others). Correct electrolyte abnormalities and address underlying causes of acquired QT prolongation."
  },
  {
    "article_id": 214,
    "article_title": "Malnutrition",
    "section_id": "39e3b0f3f2704d70abafef30b1a9e641",
    "section_title": "Assessment and Documentation",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Initial Assessment**\n\n1. Obtain complete family and patient history\n2. Perform full physical examination\n3. Measure anthropometrics (weight, height, BMI)\n4. Calculate BMI z-score\n\n**Formal Documentation in Medical Record**\n\nState the diagnosis 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\nDetermine whether malnutrition is:\n- Primary (socioeconomic) or secondary (disease-related)\n- Illness-related or non-illness related\n- Acute (<3 months) or chronic (>3 months)"
  },
  {
    "article_id": 214,
    "article_title": "Malnutrition",
    "section_id": "42fc358fdcb04d198dfb1cca8402c8b7",
    "section_title": "Management Strategy",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**For Non-Illness-Related Malnutrition**\n\n1. Address environmental and familial psychosocial factors\n2. Implement observed feeding trial with age-appropriate diet\n3. Assess response to intervention\n\n**Intervention Framework**\n\nConsider both nutrition-specific and nutrition-sensitive approaches:\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\nWork collaboratively with government, nongovernment, national, and international organizations where possible to maximize intervention success."
  },
  {
    "article_id": 215,
    "article_title": "Melanoma",
    "section_id": "def70036de444d1f8c45be2e0e3e1942",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Recognition and Referral**\n\nIdentify suspicious skin lesions by their appearance: red-brown-black colour with diffuse periphery, crusting, bleeding, pain, or itching. Pay particular attention 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. Do not delay referral pending observation of lesion changes.\n\n**Risk Stratification**\n\nIdentify patients at higher risk:\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\nProvide all patients and families with prevention advice:\n- Avoid intense midday sun exposure between 10 am and 3 pm\n- Wear protective clothing: hat, long sleeves, and pants\n- Use sunscreen (specific formulations and SPF not detailed in available guidance)\n- Counsel adolescents specifically against tanning booth use\n\n**Surveillance**\n\nFor at-risk patients, arrange frequent clinical examinations with photographic documentation to enable detection of changes over time. Establish a schedule appropriate to individual risk level and ensure prompt evaluation of any reported changes."
  },
  {
    "article_id": 216,
    "article_title": "Meningococcemia",
    "section_id": "029c02fcc60b4cfe8efddc962ab7f918",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "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, administer one of the following:\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\nObtain blood cultures and perform Gram stain of petechial scrapings, which may reveal gram-negative diplococcal organisms (*Neisseria meningitidis*).\n\n**Supportive Care**\n\nManage hypotension, shock, and disseminated intravascular coagulation with appropriate supportive measures. Monitor for complications including adrenal insufficiency, neurologic sequelae, and tissue necrosis requiring possible surgical intervention."
  },
  {
    "article_id": 219,
    "article_title": "Occult Fracture",
    "section_id": "de07a326a496470dac7df2a8f8161ccb",
    "section_title": "Diagnosis and follow-up imaging",
    "variant": "long",
    "imperatives": 1,
    "content": "When clinical examination suggests fracture but radiographs are normal, the injury should be treated as a fracture. Follow-up radiographs obtained 7–10 days after injury may reveal callus formation, confirming the diagnosis. In some cases, such as rib fractures, occult injuries may become visible radiographically over 2 weeks. Bone scan can detect occult fractures not visible on standard radiographs and may reveal multiple injuries not apparent on initial imaging.\n\nIn infants and toddlers when abuse is suspected, a skeletal survey should be performed. If the initial survey is normal but concern for occult injury remains, a follow-up survey should be completed 2 weeks later, as this may reveal fractures not apparent initially. Repeat survey can omit skull, spine, and pelvis films to reduce radiation exposure while still capturing most occult fractures."
  },
  {
    "article_id": 219,
    "article_title": "Occult Fracture",
    "section_id": "e846a1d0ce234a5f9682d51849542b6d",
    "section_title": "In short",
    "variant": "short",
    "imperatives": 1,
    "content": "- Occult fractures are bone breaks not visible on initial radiographs but suspected from clinical signs (swelling, tenderness, persistent pain) and soft tissue changes\n- Common sites in children: lateral ankle malleolus and distal humerus\n- Posterior fat pad sign at the elbow is 75% sensitive for occult fracture; anterior humeral line displacement also suggests occult injury\n- Treat as fractured: immobilise and elevate\n- Follow-up radiographs at 7–10 days show callus formation confirming diagnosis\n- Rib and other fractures may become visible radiographically over 2 weeks\n- Three weeks splint or cast immobilisation is standard treatment\n- In suspected abuse, skeletal survey needed in children under 24 months; repeat survey at 2 weeks if initial survey normal but concern remains\n- Multiple fractures raise suspicion for nonaccidental trauma\n- Transphyseal fracture in very young child lacking protective reflex suggests abuse"
  },
  {
    "article_id": 219,
    "article_title": "Occult Fracture",
    "section_id": "41b58af5da8f4ab4a9b3f5bbbc2e53f3",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Initial assessment**\n- Perform thorough clinical examination: document swelling, localised tenderness, and functional impairment\n- Obtain radiographs in at least two planes (anterior/posterior and lateral)\n- Examine soft tissue swelling to localise injury\n- At the elbow: assess for posterior fat pad sign, anterior fat pad elevation ('sail sign'), and anterior humeral line displacement\n- At the ankle: note lateral swelling suggesting lateral malleolus fracture\n\n**Immediate management of suspected occult fracture**\n- Immobilise the affected limb with splint or cast\n- Elevate the limb\n- Provide analgesia as needed\n- Reassure that immobilisation typically results in significantly reduced pain\n\n**Follow-up imaging**\n- Schedule follow-up radiographs at 7–10 days to assess for callus formation\n- For rib fractures, expect radiographic visibility over 2 weeks\n- For toddler's fracture (spiral tibia fracture): expect diffuse new periosteal bone formation 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, consult child protection team\n- In children under 24 months with suspected abuse: arrange skeletal survey\n- If initial skeletal survey is normal but concern for occult injury persists: arrange repeat survey at 2 weeks (omit skull, spine, and pelvis films on repeat to reduce radiation)"
  },
  {
    "article_id": 220,
    "article_title": "Pediatric Nutrition",
    "section_id": "eb2d103300e8499b96789ff57b299c40",
    "section_title": "Nutritional Assessment and Support",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Initial Assessment**\n\nObtain detailed history of dietary intake and feeding practices. Classify nutritional status using weight-for-length or weight-for-age measurements as appropriate to age. Assess for signs of specific micronutrient deficiencies.\n\n**Feeding Route Selection**\n\nWhen nutritional support is indicated, use enteral feeding if the gastrointestinal tract is functional. Reserve parenteral nutrition for situations where enteral access is not possible or tolerance cannot be achieved.\n\n**Monitoring During Support**\n\nAvoid overfeeding in critically ill children; this can be counterproductive. Monitor tolerance of enteral feeds and adjust composition as needed. For children receiving parenteral nutrition, individualize the formulation based on clinical status and metabolic needs rather than using 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. Assess bone health status in children with chronic illness and optimize micronutrient intake accordingly."
  },
  {
    "article_id": 222,
    "article_title": "Precocious Puberty",
    "section_id": "c46a767aa704416cae886edaa163a41f",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Initial Evaluation**\n\n1. **History and physical examination** are the foundation. Document age of onset, tempo of development, growth pattern, and any neurological symptoms. Examine 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. Refer to [[124|pediatric endocrinology]] 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**: Obtain 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**: Perform 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)**: Screen for [[171|hypothyroidism]]\n- **17-OHP, DHEA, androstenedione**: Obtain if adrenal pathology is suspected\n- **Pelvic ultrasound**: Identify ovarian tumors or cysts\n- **Abdominal ultrasound**: 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 should be determined by the endocrinology team."
  },
  {
    "article_id": 223,
    "article_title": "Recurrent Pneumonia",
    "section_id": "7a825ef126d84a7bb1649cf4243e6be0",
    "section_title": "Clinical Evaluation and Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Initial Assessment**\n\n1. **Confirm the diagnosis**: Obtain all previous chest radiographs and have them reviewed together by a pediatric radiologist with clinical context. Ensure radiographic clearing occurred between episodes to distinguish recurrence from persistence.\n\n2. **Focused history**: Ask specifically about 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**: Assess respiratory rate and lung sounds. Evaluate nutritional status, perform neurologic examination, and look for clubbing.\n\n4. **Radiographic pattern recognition**: Classify the pattern 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, order investigations in this sequence:\n\n- **Suspected aspiration**: Videofluoroscopic swallow study (with speech therapist) or fiberoptic endoscopic evaluation of swallowing; consider oesophagography, upper gastrointestinal series, gastric emptying study, or pH/impedance probe\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\nRefer to [[123|pediatric pulmonology]] 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, consider referral to a multidisciplinary aerodigestive team (pulmonologist, otolaryngologist, gastroenterologist, speech-language pathologist).\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",
    "section_id": "2f7ccdb5be914a1ba39af73fb3583e60",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Initial Evaluation**\n\nExamine the child for visible trunk asymmetry, rib hump (thoracic involvement), or flank prominence (lumbar involvement). Assess for associated features suggesting syndromic or neuromuscular scoliosis, including skin manifestations (neurofibromatosis), skeletal features (Marfan syndrome), or neurological signs.\n\nObtain a standing posteroanterior radiograph of the spine 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. Determine whether the curve is functional (flexible, correctable) or structural (fixed). Identify the anatomic location (thoracic, lumbar, or cervical) and direction of convexity.\n\nFor idiopathic scoliosis, assess skeletal maturity and document family history. 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: consider initial management with thoracolumbar spinal orthosis (TLSO) brace\n- Curves >40 degrees: surgical fusion is generally indicated\n\n**Monitoring for Complications**\n\nIn severe or progressive scoliosis, particularly neuromuscular forms, assess respiratory function. 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\nRefer to orthopedic surgery 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",
    "section_id": "77a7a94f647a440ca2298a1a50cfe797",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Initial Assessment and Stabilization**\n\nRapidly consider all treatable causes of seizure. Obtain baseline neurologic examination findings. Assess for focal neurologic findings, persistent altered mental status, or signs of increased intracranial pressure.\n\n**Consultation Triggers**\n\nRefer to neurology 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\nRefer to neurosurgery for signs of increased intracranial pressure or abnormal head imaging findings.\n\n**Diagnostic Workup**\n\nPerform electroencephalography 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. Consider lumbar puncture 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 for status epilepticus, respiratory depression secondary to antiepileptic drugs, or persistent altered mental status. Consider video electroencephalogram monitoring unit 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 when baseline neurologic examination findings are restored. Arrange primary care follow-up within 2 to 3 days and neurology follow-up within 1 to 2 weeks.\n\n**Safety Considerations**\n\nMonitor for excessive benzodiazepine use, which can cause respiratory failure."
  },
  {
    "article_id": 226,
    "article_title": "Sepsis",
    "section_id": "280fb25aae45459aa38d2406cf19f892",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 5,
    "content": "**Initial assessment and stabilization**\n\n1. Recognise [[178|septic shock]] 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. Obtain blood cultures before antibiotics\n\n3. Obtain specimens from non-blood sites (urine, cerebrospinal fluid, wound) for culture as soon as possible\n\n4. Administer first dose of antibiotics without delay; every hour of delay beyond 3 hours incrementally increases harm\n\n**Respiratory support**\n\n- Provide supplemental oxygen to all patients with sepsis to optimise oxygen delivery to tissues\n- Monitor oxygenation with pulse oximetry\n- For sepsis-induced paediatric acute [[102|[[151|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, obtain:\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- Establish intravenous access\n- Administer initial fluid bolus\n- Further support is determined by response to initial fluid resuscitation"
  },
  {
    "article_id": 229,
    "article_title": "Substance Use Disorder",
    "section_id": "0c51bcd43e8846c780a017736678ffa8",
    "section_title": "Screening and Assessment",
    "variant": "clinical",
    "imperatives": 1,
    "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, examine for signs of toxidromes on physical examination. Assess the adolescent 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\nCount the number of criteria met over the past 12 months 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 should be 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 should remain involved with the child and family, supporting their engagement with treatment, monitoring progress, and providing complementary primary care services."
  },
  {
    "article_id": 231,
    "article_title": "Testicular Torsion",
    "section_id": "88c598bb82c24edabd0933a36aec2ba5",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Immediate assessment:**\n\n1. Obtain focused history: acute onset (often nocturnal), severity of pain, presence of nausea/vomiting, abdominal or inguinal pain\n2. Perform testicular examination on all boys presenting with abdominal pain\n3. Calculate TWIST score:\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 | Consider imaging or close follow-up |\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- Obtain immediate urological surgical consultation\n- Do not delay for imaging\n- If pain duration is <4–6 hours and surgical delay is anticipated, manual detorsion may be attempted:\n  - Rotate affected testis outward toward the thigh (medial-to-lateral direction)\n  - Rotate 180° at a time\n  - Repeat as needed (up to 4 attempts, as torsion may involve up to 720° rotation)\n  - Successful detorsion produces dramatic pain relief\n- Arrange prompt surgical detorsion with bilateral orchiopexy\n- If patient is hospitalized, surgery should be performed before discharge\n\n**For intermittent torsion:**\n\n- Arrange elective bilateral orchiopexy\n- Provide clear return precautions and close follow-up instructions until surgery is performed"
  },
  {
    "article_id": 232,
    "article_title": "Viral Infection",
    "section_id": "4b9d3a62d83d4130ac7cedab3fa61739",
    "section_title": "Management of Exposure",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Identification and Assessment**\n\nFollowing potential viral exposure in hospital or community settings:\n- Identify all exposed individuals (healthcare professionals, patients, visitors)\n- Determine immunity status through clinical history or serological testing\n- Document exposure timing and route\n\n**Intervention**\n\nFor non-immune exposed individuals:\n- Administer varicella immunization if no contraindications exist\n- Administer VariZIG up to day 10 postexposure for appropriate candidates\n- If VariZIG is unavailable, consider intravenous immunoglobulin (IGIV) as alternative\n\n**Monitoring**\n\nObserve for symptom development during the incubation period. Immunocompromised individuals require closer surveillance for disseminated disease and complications."
  },
  {
    "article_id": 234,
    "article_title": "Vitamin B12 Deficiency",
    "section_id": "47d622dc77b549a4904712e2d3927517",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Diagnosis and confirmation**\n\n1. Measure serum vitamin B12 level\n2. If B12 is normal or low-normal but clinical suspicion remains high, obtain ancillary testing: methylmalonic acid and homocysteine levels\n3. Consider MRI of cervical spine if neurologic signs present (look for T2 hyperintensity in dorsal columns)\n\n**Treatment initiation**\n\nAdminister vitamin B12 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. Expect rapid clinical improvement with replacement therapy, though the duration of prior deficiency influences the likelihood of permanent neurologic sequelae."
  },
  {
    "article_id": 236,
    "article_title": "Alcohol Intoxication",
    "section_id": "9702d079cc8e40b8b537685be6355165",
    "section_title": "Management at the Bedside",
    "variant": "clinical",
    "imperatives": 10,
    "content": "**Initial assessment:**\n- Obtain blood alcohol concentration\n- Assess airway, breathing, and circulation\n- Perform secondary survey for traumatic injury ([[139|head trauma]] commonly accompanies intoxication)\n- Check blood glucose immediately\n\n**Mild intoxication (BAC <100 mg/dL):**\n- Close observation\n- Provide hydration\n- Administer analgesics as needed\n\n**Moderate to severe intoxication (BAC >300 mg/dL):**\n- Establish airway management\n- Provide artificial ventilatory support (respiratory [[204|depression]] is the primary cause of death)\n- Initiate supportive care\n\n**Hypoglycaemia management:**\n- If blood glucose <60 mg/dL: start IV infusion of D5W or D10W\n\n**Seizures:**\n- Treat with diazepam or phenytoin\n\n**Severe withdrawal symptoms:**\n- Consider benzodiazepines\n\n**Acute psychosis:**\n- Manage with haloperidol\n\n**Severe cases:**\n- Monitor for and treat cerebral oedema appropriately\n\n**Dialysis consideration:**\n- Consider when BAC >400 mg/dL\n\n**Disposition:**\n- Following acute stabilization, refer for alcohol use disorder treatment (group counselling, individualized counselling, or multifamily educational intervention)"
  }
]