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In medicine, we are admonished to always consider horses when we hear hoofbeats. However, it is not unusual to see pediatric patients presenting with common presentations of unusual conditions or uncommon presentations of routine conditions. This case-based presentation covered appendicitis in a young child, a child with a complicated headache and an unusual presentation of a viral illness. This presentation reinforces the importance of thinking outside the box when caring for patients in an urgent care setting.
Dr. Tryon says …
Take Home Tactic #1: Appendicitis in infants and young children is uncommon but not exceedingly rare. Keep it in your differential when assessing kids at all ages with abdominal pain.
Appendicitis is the most common emergency abdominal surgical condition in the pediatric population. It is estimated that the lifetime risk is 9% for boys and 7% for girls and most typically presents between the second and third decade of life (i.e. between 10-30 years of age). While rare in the neonate (birth-1month) population and uncommon in the pre-school aged (1 month – 5 years) population, be on the look-out for these signs:
For neonates, look for:
• Abdominal distention
• Decreased oral intake
• Abdominal tenderness
• Temperature instability
For preschool-aged children, look for:
• Abdominal pain
• Refusing to eat
• Localized tenderness
Take Home Tactic #2: While stroke in children is rare, headache as a presenting complaint is common. Keep it in your differential, especially with headaches with other associated symptoms or neurological findings.
Stroke, either ischemic or hemorrhagic, in the pediatric population is typically considered to be a RARE event. Estimates are that there are up to 13 stokes per 100,000 children under 18 years of age each year. Unlike adult strokes (where most are ischemic), hemorrhagic strokes account for about one half of pediatric strokes and have high morbidity and mortality rates.
For hemorrhagic stroke, the most common signs or symptoms are:
• Change in mental status
• Viral prodrome
Take Home Tactic #3: During viral season, and other times of the year, paying close attention to vital signs and your cardiac examination may help you in identifying a potential myocarditis patient.
Myocarditis in infants and children is a relatively RARE diagnosis, but mortality rates may be as high as 25% in children and 75% in infants, though incidence is likely under-represented, though, because the disease may be unrecognized.
Viral infections are the most common cause of myocarditis, including:
• Enteroviruses (Coxsakie group b)
• Parvovirus B19
• Human herpes virus 6
Overall, there are 20 known viral etiologies. Bacterial myocarditis is much less common (e.g. Borrelia burgdorferi and Lyme Disease and others).
PURCHASE THE ENTIRE ONLINE SESSION OF INTERESTING CASES IN PEDIATRIC URGENT CARE: HOOFBEATS AND HORSES HERE
Dr. Tom Tryon is a clinical urgent care physician and is the former Associate Division Director of the Section of Urgent Care for Children’s Mercy Hospital in Kansas City and a Professor of Pediatrics at the University of Missouri – Kansas City (UMKC) School of Medicine. Dr. Tryon has been a full time pediatric urgent care physician since 2006. In his previous leadership role, he oversaw the building, development and clinical operations of three pediatric urgent care centers, including a staff of approximately 70 physicians. He and wife, Jackie, a pediatric nurse, have four children (all pursuing medicine) and reside in Missouri.
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