Pediatric Examination and Board Review (133 page)

However, decreased need for sleep, grandiosity, and overinflated sense of self, if present, suggest the diagnosis of bipolar disorder.

16.
(E)
All of the following are considered predisposing factors for depression in adolescence: family history of depression in first-degree relatives, history of prior depressive episode, chronic illness, family dysfunction, peer problems, academic difficulties, learning disabilities, early losses, history of anxiety disorders or attention deficit hyperactivity disorder (ADHD), history of abuse or neglect, stress, breakup of a romantic relationship, traumatic events (eg, exposure to violence, natural disasters).

17.
(E)
All the above conditions would indicate the need for urgent psychiatric evaluation and treatment. Treatment for depressive disorders in children and adolescents often involves short-term psychotherapy, medication, or a combination of both, together with targeted interventions involving the home and school environment. Optimal treatment of a teen with depression calls for counseling in all cases. Certain types of short-term psychotherapy, particularly cognitive-behavioral therapy (CBT), have been helpful to relieve depression in children and adolescents. However, the use of antidepressant medication in children and adolescents remains controversial. Medication should be considered in adolescents with moderate to severe depression, severe vegetative symptoms, marked functional impairment, presence of psychotic symptoms, strong family history of depression, depressed phase of bipolar disorder, or failed psychotherapeutic intervention.

S
UGGESTED
R
EADING

American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior.
J Am Acad Child Adolesc Psychiatry.
2001;40:24S.

Suicide and suicide attempts in adolescents. Committee on Adolescents. American Academy of Pediatrics.
Pediatrics.
2000;105:871-874.

Bonin L.
Depression in adolescents: epidemiology, clinical manifestations, and diagnosis
. Up-to-Date Web site, 2004.
http://www.uptodateonline.com
. Accessed June 2010.

Anderson RN. Deaths: leading causes for 2000.
Natl Vital Stat
Rep.
2002;50(16):1-85.

Dietz WH, Robinson TN. Overweight children and adolescents.
N Engl J Med.
2005;352(20):2100-2109.

Joffe A, Blythe MJ. Handbook of adolescent medicine.
Adolesc
Med.
2003;14:2.

Kennebeck S, Bonin L. Epidemiology and risk factors for suicidal behavior in children and adolescents. Up-to-Date Web site, 2004.
http://www.uptodateonline.com
. Accessed June 2010.

Neinstein LS.
Adolescent Health Care: A Practical Guide.
5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

Chapter 9

GENERAL EMERGENCY AND URGENT CARE

CASE 79: A 17-YEAR-OLD WITH KNEE PAIN

A 17-year-old female high school soccer player is brought to a pediatric emergency department with a chief complaint of left knee pain. The onset of symptoms occurred during a soccer game the previous day. The athlete states that as she went to kick the ball with her right foot, she planted her left foot, felt her left knee buckle, and heard a “pop.” She then fell to the ground and had to be helped off the field. She experienced immediate swelling in the knee as well as some difficulty straightening the knee. She denied any tingling or numbness in the leg. She is using crutches because walking is painful. She denies any history of previous knee injuries and has played soccer for 7 years.

SELECT THE ONE BEST ANSWER

1.
The best initial management for this athlete on the soccer field should include

(A) ice applied to the knee joint for approximately 20 minutes

(B) application of a knee immobilizer after attempting to straighten the leg to full extension

(C) ambulation on the sidelines to improve the range of motion and decrease the swelling

(D) an immediate dose of oral (PO) ibuprofen 600-800 mg to prevent inflammation

(E) immediate transport by ambulance to the nearest emergency department for evaluation

2.
Based on the history alone, the most likely diagnosis of this girl’s injury is

(A) meniscal tear

(B) medial collateral ligament (MCL) tear

(C) anterior cruciate ligament (ACL) tear

(D) distal femur fracture

(E) patellar dislocation

3.
On physical examination, a moderate knee joint effusion and a 5-degree flexion contracture are noted. Valgus and varus testing performed at 30 degrees of knee flexion reveal no instability. An anterior drawer test performed with the knee at 90 degrees of flexion reveals increased laxity. A posterior drawer test is negative. McMurray test is negative. There is no pain with patellar compression, nor is patellar instability noted. Based on the physical examination just described, which of the following tests performed is most helpful in confirming your suspected diagnosis?

(A) valgus test

(B) varus test

(C) anterior drawer test at 90 degrees of flexion

(D) Lachman test at 30 degrees of flexion

(E) McMurray test

4.
You tell the patient that the swelling in her knee indicates inflammation is present. Which of the following statements is most accurate regarding inflammation?

(A) inflammation is primarily an acute response to trauma, infection, and autoimmune diseases

(B) nonsteroidal anti-inflammatory drugs (NSAIDs) work on joint inflammation by inhibiting prostaglandin synthesis in the arachidonic acid cascade at the cyclo-oxygenase pathway

(C) corticosteroids work most effectively on joint inflammation by inhibiting leukotriene production

(D) inflammation is characterized by erythema, edema, warmth, and pain and has a protective effect on synovium, tendons, bursae, and cartilage

(E) none of the above

5.
The patient now tells you she is in pain after you have examined her and asks what she should do. Your next step in treatment should be which of the following?

(A) apply an ACE wrap

(B) knee joint aspiration

(C) corticosteroid injection

(D) knee joint aspiration followed by a corticosteroid injection

(E) knee brace

6.
You speak with the orthopedic surgeon regarding follow-up as an outpatient. What radiographic study will best aid her in follow-up management?

(A) anteroposterior (AP) and lateral plain radiograph

(B) AP, lateral, sunrise, and notch plain radiographs

(C) computed tomography (CT) scan

(D) magnetic resonance imaging (MRI) scan

(E) no imaging study is needed

7.
Which of the following treatment recommendations is likely to result in complete recovery from the above injury including eventual return to soccer?

(A) custom hinged knee brace for 3-6 months

(B) 6-12 weeks of physical therapy in a sports rehabilitation center

(C) arthroscopic surgery and repair

(D) arthroscopic surgery and reconstruction

(E) complete rest and crutch-assisted ambulation for 6-12 weeks

8.
The same patient returns to the emergency department 2 weeks later. She is now complaining of severe sharp stabbing sensations of pain when she attempts to straighten her leg completely. Your physical examination reveals a 10-degree flexion contracture, a small joint effusion, and medial joint line tenderness. Attempts to straighten the knee into neutral (full extension at 0 degrees) reproduce the sharp pain. Laxity is again noted with a Lachman test. McMurray testing reveals a painful “click.” You are now most concerned about the following diagnosis

(A) ACL injury

(B) MCL injury

(C) meniscal injury

(D) A and C

(E) A, B, and C

9.
The patient now tells you she has been unable to go for an MRI because of her insurance and lack of transportation; however, she is planning to go in 10 days. She asks what you want her to do in the meantime. The most appropriate recommendation to make at this point is

(A) continue the brace and follow up after the MRI

(B) continue the brace and physical therapy and follow up after the MRI

(C) resume crutch use, stop physical therapy, and await the MRI

(D) referral to an orthopedic surgeon after the MRI

(E) referral to an orthopedic surgeon within 1 week, regardless of the MRI being done

10.
An 11-year-old boy presents to the pediatric emergency department complaining of pain in his right knee. He has played soccer everyday for the past 4 months on a traveling soccer team. He has noted that the pain has worsened over the past week. You are concerned about

(A) osteochondritis dissecans