1s peer: Week 6 Discussion Part ITable 1: Differential Diagnosis of Pediatric LimpComplete the table. Chief Complaint: LimpConditionAgePain (+ or -)Historical FindingsClinical FindingsCausative FactorsManagementDevelopmental Dysplasia of the HipInfancy+Breech presentation, femaleAsymmetrical gluteal folds, hip instabilityGenetic factors, breech presentation, female genderPavlik harness, hip spica casting, surgeryLeg-length InequalityAny age+Congenital or acquiredLimb length discrepancy, pelvic tilt, scoliosisTrauma, congenital disorders, infections, tumorsShoe lifts, surgical correction (depending on severity)Juvenile ArthritisChildhood+/-Family history, joint stiffnessJoint swelling, limited range of motion, morning stiffnessAutoimmune, genetic predisposition, environmental triggersNSAIDs, disease-modifying antirheumatic drugs (DMARDs), physical therapySlipped Capital Femoral Epiphysis (SCFE)Adolescence+Rapid growth, obesityHip pain, limp, limited internal rotationObesity, hormonal changes, traumaSurgical fixation, physical therapyLegg-Calvé-Perthes DiseaseChildhood+Male gender, family historyHip pain, limp, limited range of motionVascular insufficiency, genetic factors, traumaObservation, bracing, physical therapy; surgery in severe casesTransient SynovitisChildhood+Recent viral illnessHip pain, limp, possible feverViral infectionNSAIDs, rest, observationTraumaAny age+Recent injuryPain, swelling, bruising, deformityFalls, accidents, sports injuriesImmobilization, surgery (depending on severity)NeoplasmAny age+/-History of cancer, unexplained weight lossBone pain, swelling, pathological fracturesMetastasis, primary bone tumorsChemotherapy, radiation, surgery (depending on type)Septic ArthritisAny age+Recent infection, feverHip pain, fever, warmth, rednessBacterial infectionIV antibiotics, drainage, surgical debridementAcute Hematogenous OsteomyelitisChildhood+Recent infection, feverBone pain, fever, swellingBacterial infectionIV antibiotics, surgical drainage if abscess presentTable 2: Differential Diagnosis of Pediatric HeadachesComplete the table.Common TypesDiagnostic Criteria Based on HistoryTreatment/ManagementPediatric Migraine HeadacheRecurrent headaches with specific characteristics like throbbing unilateral pain, nausea, vomiting, photophobiaIdentify triggers, lifestyle modifications, NSAIDs, triptans, preventive medications (like beta-blockers or antiepileptic drugs)Tension HeadacheBilateral pressing or tightening pain, mild to moderate intensityStress management, relaxation techniques, NSAIDs, muscle relaxantsChronic Tension HeadacheFrequent tension headaches (>15 days/month) for at least 3 monthsStress management, cognitive-behavioral therapy (CBT), antidepressants, muscle relaxantsOther Differentials: List 3 Additional Differentials for HeadacheCharacteristicsManagementCluster HeadacheSevere unilateral pain around the eye, tearing, nasal congestionSinus HeadacheFacial pressure/pain, worsens with bending forward, nasal congestion, feverIntracranial HypertensionHeadache worse in the morning, pulsatile visual disturbances, papilledemaTable 3: Musculoskeletal Disorders and Sports-Related InjuriesComplete the table.DisorderDescriptionScreening Test?How to Perform Screening Test?Imaging?Treatment PlanAdolescent Idiopathic ScoliosisAbnormal lateral curvature of the spine during growth periodYesPhysical examination, Adam’s forward bending testX-rays, sometimes MRIObservation, bracing, sometimes surgeryOsgood-Schlatter DiseaseInflammation of the patellar ligament at the tibial tuberosityNoClinical examination, palpation over the tibial tuberosityUsually not requiredRest, ice, NSAIDs, stretching, strengthening exercisesMeniscal TearTear in the cartilage of the knee meniscusNoHistory, physical examination, McMurray testMRI, sometimes X-raysPhysical therapy, sometimes arthroscopic surgeryQuadriceps ContusionBruising of the quadriceps muscleNoPhysical examination, assessment of swelling and tendernessUsually not required, but ultrasound or MRI can be used if neededRest, ice, compression, elevation, NSAIDs, rehabilitation exercisesSprain of MCLSprain of the Medial Collateral LigamentNoPhysical examination, valgus stress testUsually not requiredRest, ice, compression, bracingOsteochondritis DissecansFragmentation and potential detachment of bone and cartilage within a jointNoPhysical examination, imaging (X-rays, MRI)X-rays, MRI, CT scanConservative: rest, activity modification, physical therapy; surgery in severe casesCase Scenario 1Brenda, a 13-year-old, is brought to the clinic by her mother due to a limp in her left leg that began last week. Her BMI is above the 95th percentile. She denies any history of injury, and her past medical history is unremarkable. She is able to bear weight on her left leg but experiences pain in her left hip, groin, and knee when doing so.Additional Information to GatherDetailed Symptom History: Delve into the characteristics of Brenda’s pain, including its onset, duration, intensity, and any factors that worsen or relieve it. Ask about associated symptoms like swelling, stiffness, or difficulty with movement. Inquire about her activity level, including participation in sports or physical activities.Family History: Investigate whether there is any family history of musculoskeletal disorders, such as scoliosis or other orthopedic conditions.Nutritional History: Given Brenda’s high BMI, evaluate her dietary habits and nutritional status. Ask about her intake of calcium, vitamin D, and other nutrients important for bone health, as well as any recent changes in weight or appetite.Developmental History: Review Brenda’s growth and developmental milestones. Inquire about any previous screenings for scoliosis or other musculoskeletal issues during routine pediatric visits.Psychosocial History: Assess Brenda’s psychosocial well-being, considering any stressors at home or school that might contribute to her symptoms.Examination Techniques to PerformPhysical Examination: Conduct a comprehensive musculoskeletal examination focusing on Brenda’s left hip, groin, and knee. Look for signs of tenderness, swelling, or deformity. Evaluate her gait for any asymmetry or abnormalities and assess the range of motion in her hip and knee joints, noting any limitations or discomfort.Neurological Examination: Perform a neurological assessment to rule out underlying neurological issues, including evaluating sensation, muscle strength, and reflexes in the lower extremities.Orthopedic Examination: Use specific orthopedic tests to identify potential causes of Brenda’s limp and pain. Perform the Patrick (FABER) test for hip pathology, the Ober test for iliotibial band tightness, and the McMurray test for meniscal injury in the knee.Diagnostic Tests to OrderX-rays: Obtain X-rays of Brenda’s left hip, pelvis, and knee to identify any bony abnormalities such as developmental dysplasia of the hip, Legg-Calvé-Perthes disease, or osteochondritis dissecans. X-rays may also reveal signs of osteoarthritis or fractures.MRI: If Brenda’s symptoms and examination findings indicate, an MRI of the left hip and knee should be ordered to evaluate soft tissue structures, including muscles, tendons, ligaments, and cartilage. MRI can provide detailed information about underlying pathologies such as hip dysplasia, labral tears, or meniscal tears.Blood Tests: Consider blood tests to assess Brenda’s nutritional status and to rule out systemic conditions contributing to her symptoms, such a inflammatory or autoimmune disorders.2nd peer: Part I:Table 1Differential Diagnosis Pediatric LimpConditionAge RangePainHistorical FindingsClinical FindingsCausative FactorsManagementDevelopmental Dysplasia of HipInfants to toddlers-Family history, breech position, femaleAsymmetrical gluteal folds, limited abductionGenetic predisposition, intrauterine positionPavlik harness, surgical interventionLeg-length InequalityAny age-/+History of trauma or congenital conditionsDifference in leg lengths, limpingTrauma, congenital conditionsShoe lifts, surgery if severeJuvenile Arthritis1-16 years+Morning stiffness, joint swellingJoint warmth, swelling, limited range of motionAutoimmune factorsNSAIDs, DMARDs, physical therapySlipped capital femoral epiphysis (SCFE)10-16 years+Obesity, growth spurtsLimited internal rotation, pain on hip motionMechanical stress, obesitySurgical pinningLegg-Calve-Perthes disease4-8 years+Gradual onset, limp, mild painLimited abduction and internal rotationIdiopathic, avascular necrosisObservation, physical therapy, bracing, surgeryTransient synovitis3-8 years+Recent viral infection, sudden onsetHip pain, decreased range of motionViral infectionNSAIDs, rest, observationTraumaAny age+Recent injury, fall, or accidentBruising, swelling, tendernessPhysical injuryRest, immobilization, surgery if neededNeoplasmAny age+Night pain, systemic symptomsLocalized swelling, tendernessPrimary bone tumor, metastasisChemotherapy, radiotherapy, surgerySeptic arthritisAny age+Fever, refusal to bear weightRed, swollen, warm jointBacterial infectionIV antibiotics, surgical drainageAcute hematogenous osteomyelitisAny age+Fever, malaiseLocalized pain, tenderness, possible swellingTable 2Differential Diagnosis Pediatric HeadachesCommon TypesDiagnostic Criteria Based on HistoryTreatment/ManagementPediatric Migraine HeadacheRecurrent throbbing pain, often unilateral, associated with nausea, vomiting, photophobia, phonophobiaLifestyle modifications, medications (NSAIDs, triptans), preventive medicationsTension HeadacheBilateral, dull, non-throbbing pain, typically mild to moderate intensityStress management, relaxation techniques, NSAIDsChronic Tension HeadacheSimilar to tension headache but occurring more than 15 days per month for at least 3 monthsPsychological counseling, stress reduction, medicationsOther DifferentialsCharacteristicsManagementCluster HeadachesSevere unilateral pain, autonomic symptomsOxygen therapy, triptans, preventive medsSinusitis-related HeadachesPain over sinuses, worsened by bending forwardAntibiotics (if bacterial), decongestantsIntracranial HypertensionVisual disturbances, papilledemaWeight reduction, medications, shuntingTable 3Musculoskeletal Disorders and Sports-Related InjuriesMusculoskeletal Disorders and Sports-Related InjuriesDescriptionScreening Test?How do you perform the screening test?Imaging?Treatment PlanAdolescent Idiopathic ScoliosisAbnormal lateral curvature of the spine, typically during adolescenceYes (routine screening in adolescents)Adam’s forward bend test: Observe for asymmetry or rib humpX-ray of the spineObservation, bracing, physical therapy, surgery if severeOsgood-Schlatter DiseasePainful inflammation of the growth plate at the tibial tuberosity, common in adolescentsNoClinical diagnosis based on symptoms and physical examinationX-ray of the kneeRest, ice, NSAIDs, stretching and strengthening exercises, rarely surgeryMeniscal TearTear in the fibrocartilage of the knee joint, often due to twisting or direct traumaClinical diagnosisMcMurray test: Assesses for joint clicking or locking with specific knee movementsMRI of the kneeRest, ice, NSAIDs, physical therapy, arthroscopic surgery in severe casesQuadriceps ContusionBruising of the quadriceps muscle typically due to direct traumaNoClinical diagnosis based on history and physical examinationX-ray (to rule out fracture)Rest, ice, compression, elevation, NSAIDs, stretching and strengthening exercisesSprain of MCLStretch or tear of the medial collateral ligament of the knee, often due to valgus stress or twistingClinical diagnosisValgus stress test: Assess for joint instability or pain at the medial aspect of the kneeMRI of the kneeRest, ice, compression, elevation, bracing, physical therapy, rarely surgeryOsteochondritis dissecansA condition where a fragment of bone and cartilage becomes detached from the end of a boneClinical diagnosisClinical diagnosis based on symptoms, physical examination, and imaging findingsX-ray of the affected jointRest, immobilization, physical therapy, surgery in severe casesPart II:Case Scenario 1: Brenda is a 13-year-old brought into the clinic by her mother for a left leg limp she developed last week. Brendas BMI is >95%. She reports no history of injury, and her past medical history is unremarkable. She can bear weight on her left leg but complains of left hip, groin, and knee pain when she does.What more should you know about Brenda?oDetailed Medical History: Explore any recent changes in Brenda’s physical activity, any recent illnesses or infections, any family history of musculoskeletal issues or metabolic disorders, and her dietary habits.oSocial History: Inquire about Brenda’s daily activities, including her level of physical activity, sports participation, and any recent changes in routine.Review of Systems: Ask about any other symptoms Brenda may be experiencing, such as fever, fatigue, or joint swelling.What specific exam techniques should you perform and why?oMusculoskeletal Examination: Assess Brenda’s gait, observing for any asymmetry or abnormalities. Palpate the left hip, groin, and knee for tenderness, swelling, or warmth. Evaluate Brenda’s range of motion in the left hip, paying attention to any limitations or pain with movement.oNeurological Examination: Check Brenda’s sensation and strength in the left leg, including testing reflexes. Evaluate for any signs of nerve involvement or neurological deficits.oAssessment of Growth and Development: Given Brenda’s high BMI, assess her growth chart and inquire about any recent changes in weight or height.Assessment of Puberty Stage: Given Brenda’s age, assess her pubertal development to ensure she is within the expected range for her age.What diagnostic tests should you order and why?oX-rays: X-rays of the left hip, groin, and knee can help identify any bony abnormalities, fractures, or signs of bone deformities such as slipped capital femoral epiphysis (SCFE), which is more common in overweight adolescents.oBlood Tests: Blood tests may include a complete blood count (CBC) to rule out infection or anemia and inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess for inflammation.oBone Density Test: Given Brenda’s high BMI, assessing her bone density may be important to evaluate for signs of osteoporosis or other bone abnormalities.Ultrasound or MRI: These imaging studies may be ordered to further evaluate soft tissue structures around the hip joint, such as tendons, ligaments, or cartilage, and to assess for any signs of hip joint pathology.Hello everyone, hope you are all having a great start of your week!Part I:Table 1Differential Diagnosis Pediatric LimpConditionAge RangePainHistorical FindingsClinical FindingsCausative FactorsManagementDevelopmental Dysplasia of HipInfants to toddlers-Family history, breech position, femaleAsymmetrical gluteal folds, limited abductionGenetic predisposition, intrauterine positionPavlik harness, surgical interventionLeg-length InequalityAny age-/+History of trauma or congenital conditionsDifference in leg lengths, limpingTrauma, congenital conditionsShoe lifts, surgery if severeJuvenile Arthritis1-16 years+Morning stiffness, joint swellingJoint warmth, swelling, limited range of motionAutoimmune factorsNSAIDs, DMARDs, physical therapySlipped capital femoral epiphysis (SCFE)10-16 years+Obesity, growth spurtsLimited internal rotation, pain on hip motionMechanical stress, obesitySurgical pinningLegg-Calve-Perthes disease4-8 years+Gradual onset, limp, mild painLimited abduction and internal rotationIdiopathic, avascular necrosisObservation, physical therapy, bracing, surgeryTransient synovitis3-8 years+Recent viral infection, sudden onsetHip pain, decreased range of motionViral infectionNSAIDs, rest, observationTraumaAny age+Recent injury, fall, or accidentBruising, swelling, tendernessPhysical injuryRest, immobilization, surgery if neededNeoplasmAny age+Night pain, systemic symptomsLocalized swelling, tendernessPrimary bone tumor, metastasisChemotherapy, radiotherapy, surgerySeptic arthritisAny age+Fever, refusal to bear weightRed, swollen, warm jointBacterial infectionIV antibiotics, surgical drainageAcute hematogenous osteomyelitisAny age+Fever, malaiseLocalized pain, tenderness, possible swellingTable 2Differential Diagnosis Pediatric HeadachesCommon TypesDiagnostic Criteria Based on HistoryTreatment/ManagementPediatric Migraine HeadacheRecurrent throbbing pain, often unilateral, associated with nausea, vomiting, photophobia, phonophobiaLifestyle modifications, medications (NSAIDs, triptans), preventive medicationsTension HeadacheBilateral, dull, non-throbbing pain, typically mild to moderate intensityStress management, relaxation techniques, NSAIDsChronic Tension HeadacheSimilar to tension headache but occurring more than 15 days per month for at least 3 monthsPsychological counseling, stress reduction, medicationsOther DifferentialsCharacteristicsManagementCluster HeadachesSevere unilateral pain, autonomic symptomsOxygen therapy, triptans, preventive medsSinusitis-related HeadachesPain over sinuses, worsened by bending forwardAntibiotics (if bacterial), decongestantsIntracranial HypertensionVisual disturbances, papilledemaWeight reduction, medications, shuntingTable 3Musculoskeletal Disorders and Sports-Related InjuriesMusculoskeletal Disorders and Sports-Related InjuriesDescriptionScreening Test?How do you perform the screening test?Imaging?Treatment PlanAdolescent Idiopathic ScoliosisAbnormal lateral curvature of the spine, typically during adolescenceYes (routine screening in adolescents)Adam’s forward bend test: Observe for asymmetry or rib humpX-ray of the spineObservation, bracing, physical therapy, surgery if severeOsgood-Schlatter DiseasePainful inflammation of the growth plate at the tibial tuberosity, common in adolescentsNoClinical diagnosis based on symptoms and physical examinationX-ray of the kneeRest, ice, NSAIDs, stretching and strengthening exercises, rarely surgeryMeniscal TearTear in the fibrocartilage of the knee joint, often due to twisting or direct traumaClinical diagnosisMcMurray test: Assesses for joint clicking or locking with specific knee movementsMRI of the kneeRest, ice, NSAIDs, physical therapy, arthroscopic surgery in severe casesQuadriceps ContusionBruising of the quadriceps muscle typically due to direct traumaNoClinical diagnosis based on history and physical examinationX-ray (to rule out fracture)Rest, ice, compression, elevation, NSAIDs, stretching and strengthening exercisesSprain of MCLStretch or tear of the medial collateral ligament of the knee, often due to valgus stress or twistingClinical diagnosisValgus stress test: Assess for joint instability or pain at the medial aspect of the kneeMRI of the kneeRest, ice, compression, elevation, bracing, physical therapy, rarely surgeryOsteochondritis dissecansA condition where a fragment of bone and cartilage becomes detached from the end of a boneClinical diagnosisClinical diagnosis based on symptoms, physical examination, and imaging findingsX-ray of the affected jointRest, immobilization, physical therapy, surgery in severe casesPart II:Case Scenario 1: Brenda is a 13-year-old brought into the clinic by her mother for a left leg limp she developed last week. Brendas BMI is >95%. She reports no history of injury, and her past medical history is unremarkable. She can bear weight on her left leg but complains of left hip, groin, and knee pain when she does.What more should you know about Brenda?o Detailed Medical History: Explore any recent changes in Brenda’s physical activity, any recent illnesses or infections, any family history of musculoskeletal issues or metabolic disorders, and her dietary habits.o Social History: Inquire about Brenda’s daily activities, including her level of physical activity, sports participation, and any recent changes in routine.Review of Systems: Ask about any other symptoms Brenda may be experiencing, such as fever, fatigue, or joint swelling.What specific exam techniques should you perform and why?o Musculoskeletal Examination: Assess Brenda’s gait, observing for any asymmetry or abnormalities. Palpate the left hip, groin, and knee for tenderness, swelling, or warmth. Evaluate Brenda’s range of motion in the left hip, paying attention to any limitations or pain with movement.o Neurological Examination: Check Brenda’s sensation and strength in the left leg, including testing reflexes. Evaluate for any signs of nerve involvement or neurological deficits.o Assessment of Growth and Development: Given Brenda’s high BMI, assess her growth chart and inquire about any recent changes in weight or height.Assessment of Puberty Stage: Given Brenda’s age, assess her pubertal development to ensure she is within the expected range for her age.What diagnostic tests should you order and why?o X-rays: X-rays of the left hip, groin, and knee can help identify any bony abnormalities, fractures, or signs of bone deformities such as slipped capital femoral epiphysis (SCFE), which is more common in overweight adolescents.o Blood Tests: Blood tests may include a complete blood count (CBC) to rule out infection or anemia and inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess for inflammation.o Bone Density Test: Given Brenda’s high BMI, assessing her bone density may be important to evaluate for signs of osteoporosis or other bone abnormalities.Ultrasound or MRI: These imaging studies may be ordered to further evaluate soft tissue structures around the hip joint, such as tendons, ligaments, or cartilage, and to assess for any signs of hip joint pathology.
