PowerPoint Presentation

Document Sample
PowerPoint Presentation Powered By Docstoc
					 Visual Diagnosis
   Rakesh D. Mistry, MD, MS
 Division of Emergency Medicine
Children’s Hospital of Philadelphia

                                      1
8 mo. with fever and diaper rash




                                   2
 8 mo. with fever and diaper rash
Differential Diagnosis
   –   Bullous impetigo
   –   S. aureus scalded skin
   –   Erysipelas
   –   Perianal group A strep
   –   Stevens-Johnson
   –   Partial-thickness burn



                                    3
Erysipelas




             4
10 y.o. male with rash on leg




                                5
                   Ecthyma
• Local necrotizing skin
  infection
• Microbiology
   – Streptococcus pyogenes
     (GABHS)
   – S. aureus
   – Pseudomonas aeurginosa
• Systemic
   – Ecthyma gangrenosa
   – Immune deficiency        6
Ecthyma




          7
Bullous impetigo




                   8
4 y.o. girl with progressive facial
        swelling and fever




                                  9
               Facial Swelling
•   Dental abscess
•   Facial cellulitis
•   Parotitis
•   Sinusitis
•   Lymphadenitis
•   Insect bite

                                 10
Another view…




                11
            Facial Cellulitis
• Microbiology
  – Staphylococcus aureus
  – Group A ß-hemolytic Streptococcus (GABHS)
  – Haemophilus tnfluenzae type B

• Treatment:
  – Cephalosporins, clindamycin
  – Consider IV
                                            12
6 y.o. male with fever, neck
 swelling, pain with eating




                               13
Parotitis
     • Displaces ear
     • Obscures inferior border
       and angle of mandible
     • Microbiology
        –   S. aureus
        –   Oral flora
        –   Infuenzae
        –   Coxsackie/Enteroviruses
        –   Mumps
        –   HIV
     • Consider imaging for
       abscess

                                      14
                       Lymphadenitis
• Microbiology
   –   GABHS
   –   H. influenzae
   –   S. aureus
   –   Oral flora


• Treatment
   – Ampicillin/Sulbactam
   – Clindamycin
   – Consider imaging for
     abscess

                                       15
12 mo. female with “rash”




                            16
        Popsicle Panniculitis
• Extended contact with cold
• Subcutaneous fat necrosis
• Benign condition: Reassurance




                                  17
5 y.o. girl with blood in
       underwear




                            18
              Urethral Prolapse
• Pre-pubertal girls

• Associated with constipation, increased abdominal
  pressure

• Management
   – Sitz baths and reassurance
   – Topical estrogen cream
   – Urology follow-up

                                                  19
13 y.o female with 6 months of
   episodic abdominal pain




                                 20
              Hematocolpos
•   Imperforate hymen
•   Primary amenorrhea
•   Abdominal mass
•   Treatment: Surgical




                             21
22
23
             Electrical Burn
• Differential
  – Caustic ingestion
  – Infectious


• Risk for delayed labial artery bleed



                                         24
15 y.o. fever, sore throat,
     abdominal pain




                              25
        15 y.o. fever, sore throat,
             abdominal pain
• Differential Diagnosis       • Diagnosed
   –   GABHS                         GABHS (+)
   –   N. gonorrhea            • Placed on penicillin
   –   Adenovirus
   –   Influenza
   –   Mononucleosis
        • Epstien-Barr Virus
          (EBV)
        • Cytolomegalovirus
          (CMV)

                                                        26
Non-compliant…Returns in 5 days




                                  27
          Peritonsillar Abscess
•   Older children and adolescents
•   “Hot-potato” voice
•   Trismus and drooling
•   Management
    – Needle aspiration
    – Antibiotic therapy


                                     28
14 y.o. male with fever, neck
    pain, and dysphagia




                                29
Ludwig’s Angina




                  30
           Ludwig’s Angina
• Submandibular/sublingual infection
• Rapidly progressive
• Management
  – Monitor airway
  – IV antibiotics
  – Surgical drainage


                                       31
18 mo. “not using hands”




                           32
18 mo. “not using hands”




                           33
         Vitamin D Deficiency
• Hypocalcemia
• Dietary
• Skeletal findings
   – Bowing
   – Epiphyseal widening
   – “Rachitic rosary”




                                34
3 y.o. girl not using right arm




                                  35
     Radial Head Subluxation
• Typical appearance of well-appearing child
  not using affected arm

• Reduction
  – Supination-Flexion
  – Pronation-Extension


                                           36
 8 y.o. female with fatigue and
dyspnea on exertion for 2 weeks




                              37
Pallor




         38
Anemia
   • Typically appears with
     hemoglobin ~8 gm/dL

   • Anemia
      –   Nutritional
      –   Blood loss
      –   Malignancy
      –   RBC destruction

                            39
40
Infant with severe diarrhea




                              41
42
            Central Cyanosis
•   Severe pulmonary disease
•   Shock
•   R L cardiac shunt
•   Polycythemia
•   Abnormal hemoglobin states



                                 43
            Methemoglobinemia
• Oxidative stress: diarrhea,
  dehydration, acidosis

• Methemogobin cannot
  carry O2  tissue hypoxia

• Fluid resucitation

• Methylene blue

                                44
Fever and spreading rash




                           45
46
                Petechiae
• Meningococemia
• Viral exanthem
• Rocky Mountain Spotted Fever
      (Rickettsia rickettsi)
• Immune Thrombocytopenic
      Purpura
• Mechanical

                                 47
5 y.o. male casted 3 days ago for
presumed fracture, now with rash




                                48
49
Henoch-Schonlein Purpura
            • Presentation
               –   Palpable purpura
               –   Joint swelling and pain
               –   Abdominal Pain
               –   Renal involvement

            • Management
               – Pain control
               – Urinalysis
               – Consider steroids
                                         50
51
Malar Rash: Systemic Lupus
   Erythematosus (SLE)




                             52
14 year old boy with painful rash
      on face and eye pain




                                53
                 Herpes Zoster
• Dermatomal
  distribution
• Pain control

• IV or PO Acyclovir

• Trigeminal nerve:
  suspect ocular disease
                                 54
3 y.o. with “finger infection”




                                 55
56
          Herpetic Whitlow
• Differential Diagnosis
  – Paronychia
  – Bullous impetigo


• Do not incise

• Treat symptomatically
                             57
2 y.o. history of dry skin, now red
            painful rash




                                      58
Eczema Herpeticum




                    59
3 y.o. girl with rash on face




                                60
61
62
   Herpes Keratoconjunctivitis
• Analgesia

• Topical Acyclovir

• Do not use steroids!



                                 63
21 mo.female with right eye
    swelling and fever




                              64
              Eye Swelling
•   Conjunctivitis
•   Periorbital cellultiis
•   Orbital cellulitis
•   Insect bite
•   Allergic reaction
•   Hypoproteinemia (Nephrotic Syndrome)
•   Epstien-Barr Virus
                                           65
Poked in eye at school




                         66
            Open Globe Injury
• Iris plugs defect misshapen pupil
• Stop examination immediately
     Cover eye with hard protective shield
     Consult ophthalmology
     Avoid increases in intraocular pressure
     No ointments or drops

                                                67
Neonate with fever and pus from
       umbilical stump




                                  68
                Omphalitis
Differential
• Infected urachal cyst
• Umbilical hernia
• Patent omphalomesenteric
  duct




                             69
4 y.o. backseat passenger in motor
           vehicle crash




                                     70
       Seatbelt/Lapbelt Injury
• Abdominal or pelvic bruising
• Intra-abdominal injuries
  • Hollow viscus
  • Solid organs
• Lumbar spine fracture (Chance fracture)
• Management
  • Abdominal CT
  • Admit for serial exams
                                            71
20 mo. male was “playing rough”
         with brother




                                  72
73
Child Abuse
      • Multiple bruises

      • Soft tissues-not over
        bony prominences

      • Shape of fist or pinch

      • Loop-belt or cord
        marks
                                 74
3 week-old with eye swelling




                               75
3 week-old with eye swelling




                               76
77
            Orbital Tumor
• Neuroblastoma

• Retinoblastoma (usually within globe)




                                          78
79
      Ophthalmia Neonatorum

• Chlamydia trachomatis

• Neisseria gonhorrheae




                              80
12 mo. female with rash




                          81
82
        12 mo. female with rash
• Differential Diagnosis
  –   Urticaria
  –   Stevens-Johnson Syndrome
  –   Erythema Migrans (Lyme Disease)
  –   Erythema Multiforme




                                        83
   Erythema Multiforme Minor
• Infectious
  – Epstein-Barr Virus (EBV)
  – Mycoplasma
• Serum sickness
• Autoimmune disease
• Malignancy


                               84
Teenager with fever, rash, red eyes




                                      85
 Teenager with fever, rash, red eyes
• Differential Diagnosis
   – Adenovirus
   – Kawasaki syndrome
   – Stevens-Johnson
     Syndrome




                                       86
      Stevens-Johnson Syndrome
•   Erythema multiforme major
•   Mucosal surfaces
•   Etiology: infections? medications?
•   Severe cases: exfoliating, similar to burn




                                                 87
88
12 y.o. male with painful leg rash




                                 89
90
Erythema Nodosum
        • Painful, well-
          circumscribed nodules

        • Etiology
          – Infectious
          – Medications
          – Inflammatory bowel
            disease
          – Malignancy
                                 91
92
             Uvular Swelling
•   Allergic/angioedema
•   Infection (GABHS)
•   Trauma
•   Thermal or Chemical irritation




                                     93
Recurrent infection of outer ear




                                   94
The other ear…
       • Pre-auricular sinus and
         cyst

       • Diagnosis
          – Neonatal period
          – Infection later in life


       • Associated with
         deafness
                                      95
8 y.o. fever, headache, vomiting




                                   96
8 y.o. fever, headache, vomiting




                                   97
            Pott’s Puffy Tumor
• Sinusitis with:
  –   Scalp swelling
  –   Osetomyelitis and anterior erosion
  –   Extradural abscess
  –   Intracrania abscess




                                           98
99
2 y.o. thigh pain and redness




                                100
   2 y.o. thigh pain and redness
• Differential Diagnosis
  –   Cellulitis
  –   Skin abscess
  –   Osteomyelitis with fistula
  –   Retained foreign body
  –   Spider bite



                                   101
                Skin Abscess
• Methicillin-resistant S.
  aureus (MRSA)

• Incision and drainage
  paramount

• Clindamycin or
  trimethoprim-sulfa

                               102
103
104
105
Venomous Snake Bite




                      106
       Venomous Snake Bite
• Crotalinae family, or
  “pit vipers”
  – Vertical, elliptical pupils
  – Triangular head
  – Single row of caudal
    plates, or rattle


                                  107
       Venomous Snake Bite
• Immobilize            • NOT indicated
  extremity below         – Incision and suction
  heart                   – Tourniquet
                          – Cryotherapy
• Anti-venin required



                                              108
109
110
10 y.o. girl with fever, left eye
      pain, and diplopia




                                    111
           Orbtal Myositis
• Pain
• Fever
• Ocular muscle
  paresis
• Proptosis



                             112
14 y.o. female with “uneven
   smile” noted this AM




                              113
Peripheral Facial Nerve Palsy
               • Common etiologies
                 – Idiopathic (Bell’s Palsy)
                 – Borrelia burgdorferi
                   (Lyme Disease)
                 – Varicella-Zoster
                   (Ramsay Hunt Syndrome)
                 – Herpes Simplex Virus
                 – Epstein-Barr Virus (EBV)


                                       114
  Peripheral Facial Nerve Palsy
• Treatment
  –   Fluoroscein eye
  –   Eye patching and lubricant
  –   Presence of Otitis media is ENT emergency!
  –   Treat underlying condition if noted
  –   Empiric steroids and acyclovir controversial



                                                     115

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:45
posted:9/29/2012
language:Unknown
pages:115