Dermatology
Acne
- Comedones are noninflammatory acne lesions.
- Inflammatory lesions include papules, pustules, and nodules.
- Grading acne based on the type of lesion and severity helps guide therapy.
- Noninflammatory Acne
- Topical retinoids prevent the formation of comedones and reduce their number, and are indicated as monotherapy
- Mild to moderate inflammatory or mixed acne
- Topical antibiotics
- Moderate to severe acne
- Oral antibiotics
- Severe, recalcitrant acne
- Oral isotretinoin
Orthopedic
Foot disorders
Calcaneal apophysitis
- Presentation:
- also known as Sever disease, is the most common etiology of heel pain in children, usually occurring between 5 and 11 years of age.
- It is thought that in these children the bones grow faster than the muscles and tendons.
- A tight Achilles tendon then pulls on its insertion site at the posterior calcaneus with repetitive running or jumping activities, causing microtrauma to the area.
- There may be swelling and tenderness in this area and passive dorsiflexion may increase the pain.
- Radiography
- is usually normal and therefore does not often aid in the diagnosis, but it may reveal a fragmented or sclerotic calcaneal apophysis.
- Treatment
- involves decreasing pain-inducing activities, anti-inflammatory or analgesic medication if needed, ice, stretching and strengthening of the gastrocnemius-soleus complex, and the use of orthotic devices.
Plantar fasciitis and heel pad syndrome
- cause pain on the plantar surface of the heel rather than posteriorly.
Achilles tendinopathy
- causes tenderness to palpation of the Achilles tendon.
Tarsal tunnel syndrome
- related to compression of the posterior tibial nerve causes neuropathic pain and numbness in the posteromedial ankle and heel.
SCFE
- Slipped capital femoral epiphysis (SCFE)
- This is more frequent in males than in females, and is more common in African-Americans and Pacific Islanders than in whites.
- Although some patients present with pain, many present with a painless limp or vague pain.
- The average age of onset is 13.5 years for males and 12 years for females.
- Obesity is strongly associated with SCFE.
- The lack of systemic symptoms makes osteomyelitis, abscess, or a septic joint much less likely.
- Malignancy is a possibility, but night pain would be more likely.
- Sacroiliitis is much less likely given a negative FABER test.
- The patient’s age makes transient synovitis or Legg-Calvé-Perthes disease less likely.
- Although muscle strain is a possibility, the physical examination findings of external rotation deformity and limited internal rotation are more specific for SCFE.
- Once the diagnosis of SCFE is made, the patient should not bear weight and should be referred promptly for surgery to prevent complications.
Pulmonology
Asthma
Chlamydial pneumonia
- is usually seen in infants 3–16 weeks of age, and these patients frequently have been sick for several weeks.
- The infant appears nontoxic and is afebrile, but is tachypneic with a prominent cough.
- The physical examination will reveal diffuse crackles with few wheezes, and conjunctivitis is present in about 50% of cases.
- A chest film will show hyperinflation and diffuse interstitial or patchy infiltrates.
Staphylococcal pneumonia
- has a sudden onset.
- The infant appears very ill and has a fever, and initially may have an expiratory wheeze simulating bronchiolitis.
- Signs of abdominal distress, tachypnea, dyspnea, and localized or diffuse bronchopneumonia or lobar disease may be present.
- The WBC count will show a prominent leukocytosis.
Respiratory syncytial virus
- infections start with rhinorrhea and pharyngitis, followed in 1–3 days by a cough and wheezing.
- Auscultation of the lungs will reveal diffuse rhonchi, fine crackles, and wheezes, but the chest film is often normal.
- If the illness progresses, coughing and wheezing increase, air hunger and intercostal retractions develop, and evidence of hyperexpansion of the chest is seen.
- In some infants the course of the illness may be similar to that of pneumonia.
- Rash or conjunctivitis may occur occasionally, and fever is an inconsistent sign.
- The WBC count will be normal or elevated, and the differential may be normal or shifted either to the right or left.
Chlamydial infections
- can be differentiated from respiratory syncytial virus infections by a history of conjunctivitis, the subacute onset and absence of fever, and the mild wheezing.
- There may also be eosinophilia.
Parainfluenza virus infection
- presents with typical cold symptoms.
- Eight percent of infections affect the upper respiratory tract.
- In children hospitalized for severe respiratory illness, parainfluenza viruses account for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis, bronchiolitis, and pneumonia.
Obstructive Sleep Apnea
Childhood obstructive sleep apnea syndrome
- has a prevalence rate of 5.7%. It is associated with growth, cardiovascular, and neurobehavioral abnormalities.
- Adenotonsillectomy is the treatment of choice.
- Although CPAP can be effective, compliance is poor and it is therefore not a first-line treatment.
- Intranasal corticosteroids may also be helpful, but the benefit appears small.