The Approach to the Adolescent With Leg Pain

The Approach to the Adolescent With Leg Pain

The Approach to the Adolescent With Leg Pain

Extremity pain is a common problem in all age groups. It may be difficult to distinguish between bone, muscle, joint or referred pain. A younger child may not even be able to localize the pain.

Differential Diagnosis
The differential diagnosis changes with the age, history and physical examination of the patient.

In infancy and toddlerhood (see also childhood and adolescence)
Transient synovitis
Septic arthritis/osteomyelitis
Hypermobility
Diskitis
Trauma
Child Abuse
Neoplasia (including leukemias and metastatic disease)
Juvenile rheumatoid arthritis
Referred pain
Rubella

In childhood (see also infancy and toddlerhood and adolescence)
Sickle cell pain crisis
Neoplasia (including primary bone tumors)
Legg-Calve-Perthes Disease
Serum sickness
Henoch-Schonlein purpura
Collagen vascular diseases (SLE, dermatomyositis, sarcoid)
Rheumatic fever
Drugs
Porphyria
Caffey's Disease
Spondyloarthropathy
Psychological/Behavioral
Non-specific limb pain such as 'growing pains'
Abdominal abscess

In adolescence (see also infancy and toddlerhood and childhood)
Slipped capital femoral epiphysis (SCFE)
Osgood-Schlatter disease
Sexually transmitted diseases (Syphilis, Neisseria gonorrhea)
Typhoid fever
Inflammatory Bowel Disease
Osteochondritis

History and Physical
History should include onset of the symptoms, severity, intermittent or constant pain, and associated symptoms such as limp, refusal to bear weight, fever and rash. A history of preceding upper respiratory infections or trauma (especially minor trauma such as a toddler fall or even new shoes that have rubbed the feet). A close physical examination of the entire affected limb and proximal areas to the affected site (looking for sources of referred pain) such as the shoulder, neck, lower abdomen, pelvis and spine is important. Inspection for swelling and erythema should be done with palpation of muscle and bone and notation of localized heat. Additionally, range of motion of all joints should be noted. A neuromuscular examination including gait should be assessed. A general physical examination for signs of systemic infection is also indicated.

Evaluation
The laboratory evaluation could be quite extensive but should be guided the clinical situation and differential diagnoses being entertained. Tests to consider are:

Blood
CBC, Differential, Platelet - for infections, malignancy
Blood culture - for bacteremia
ESR - for evidence of inflammation

Imaging
Extremity radiographs - for trauma, primary malignancy
Computed tomography - for better delineation of a bone or soft tissue lesion

Other
ANA, Rheumatoid Factor - for connective tissue diseases
Total Protein, albumin - for inflammatory bowel disease, neoplasia
Alkaline Phosphatase, uric acid - for neoplasia
Urethral and cervical cultures - for Neisseria gonorrhea
RPR - for syphilis

Consultation
Orthopaedic Surgery for possible surgical management

Treatment
Most children usually have a self-limited, localized disease process such as transient synovitis or trauma. These can be treated with conservative management including rest, limited immobilization, thermotherapy, and pain relief. More complicated orthopaedic disease such as Legg-Perthes, and SCFE need orthopaedic management. If an infectious disease is suspected, appropriate antibiotics should be administered. Systemic diseases such as connective tissue disease, inflammatory bowel disease, and neoplasias require a team approach to the evaluation and management.

A 20-year-old man has had an 8-year history of recurrent episodes of loss of conscious activity that last for seconds to several minutes. Sometimes he has as many as 100 of these lapses. The patient regains awareness of his environment very quickly. There is no major motor manifestation during the episodes or a period of confusion afterward. The patient's neurologic examination is totally normal. Which of the following drugs would be the most effective for this patient's problem?

A Phenytoin
B Carbamazepine
C Phenobarbital
D Ethosuximide
E Primidone

The answer is D
Different types of seizures respond better to certain classes of anticonvulsant drugs. For example, generalized tonic-clonic seizures may be treated successfully with phenytoin, carbamazepine, phenobarbital, or valproic acid. Carbamazepine and phenytoin also are effective for the treatment of partial seizures, though persons with complex partial seizures may require more than one type of drug at a time. Partial absence seizures, such as those described in the question, are best treated with ethosuximide or valproic acid, although clonazepam (a benzodiazepine) also may be effective. The side effects of ethosuximide include ataxia, lethargy, GI irritation, skin rash, and bone marrow suppression

A 50-year-old man on rare occasions develops dysphagia after eating steak. He remains asymptomatic between episodes with the symptom-free intervals sometimes lasting several years. Which entity is associated with this clinical situation?

a. Schatzki ring
b. Barrett's esophagus
c. History of lye ingestion at age 14
d. Achalasia
e. Scleroderma

The correct answer is a
a. Achalasia is associated with dysphagia or regurgitation of food at night when recumbent. The food lies in the esophagus due to a high pressure of the lower esophageal sphincter, which fails to relax. There is absent peristalsis. It may also lead to an increased incidence of squamous cell carcinoma. Dysphagia may be due to abnormalities of peristalsis in the body of the esophagus, or disordered functioning of the lower esophageal sphincter or the upper esophageal sphincter (cricopharyngeus) or pharyngeal muscles. Patients with a Schatzki ring usually have occasional episodes of dysphagia, especially if large pieces of meat are not adequately chewed. Barrett's esophagus is columnar mucosa, which occurs in patients with severe gastroesophageal reflux and frequently is associated with benign peptic strictures. It may develop into adenocarcinoma after a period of time, but it is not associated with squamous cell carcinoma of the esophagus.
Scleroderma may lead to severe heartburn because of both a low esophageal sphincter pressure and an ineffective to absent peristalsis in approximately the lower two-thirds of the esophagus. A history of lye ingestion may be associated with a stricture, which causes dysphagia and may lead to the development of squamous cell carcinoma, which interferes with swallowing one's own saliva when it almost totally occludes the lumen.

A geriatric patient with osteoporosis, poor wound healing, diabetes mellitus may be having an adverse reaction to which drug?

a. Anticholinergic
b. Digoxin
c. Diuretic
d. Corticosteroid
e. Aminoglycoside

D

1. Anticholinergic drugs can worsen glaucoma and cause constipation and urinary retention, especially in elderly patients. Digoxin causes gastrointestinal adverse effects such as nausea and vomiting and anorexia. Digoxin toxicity can also cause arrhythmias and heart block. Diuretics can cause dehydration, hypokalemia, and hyponatremia. Corticosteroids can cause osteoporosis if given on a long-term basis. They also impair wound healing and precipitate or exacerbate diabetes mellitus. The aminoglycosides primarily cause renal and ototoxicity, including tinnitus and deafness.

Which statement regarding spontaneous bacterial peritonitis (SBP) is true?

a. It develops when bacteria pass directly through the bowel wall into the peritoneum.
b. It can develop in a cirrhotic patient without ascites.
c. It is treated with a combination of an aminoglycoside and ampicillin.
d. An elevated ascitic fluid polymorphonuclear leukocyte count of 250/mm3 or greater is consistent with the diagnosis.
e. Patients with SBP always have abdominal pain.

D

according to the washington manual,
SBP occurs only in patient with preexisting ascites.
the disease may be present in the absence of specific
clinical sx.
dx. - PMN >250/microliter or positive culture
tx. - 3rd generation cepha.(cefotaxime ) for 5-7days
AMG should be avoided due to renal failure
norfloxacin 400mg po qd reduces SBP recurrence, but does not improve survival