A 15-year-old girl presents with a 2-day history of pain and swelling in her left knee. She plays soccer regularly on her school team. There is no history of trauma. On physical examination, there is marked swelling and tenderness over her anterior tibial tuberosity. A radiograph of her left knee reveals irregularities of the tubercle contour and haziness of the adjacent metaphyseal border.
Which of the following is the most likely explanation for her symptoms?
Correct Answer E:
Osgood-Schlatter disease is a common cause of anterior knee pain in the adolescent. It is a stress reaction of the insertion of the patella tendon into the tibia tubercle. The condition previously was more common in adolescent boys near the time of their growth spurt; however, girls are being seen more frequently with this diagnosis owing to more active sports participation. There can be some fragmentation of the ossicles of the developing tibia tubercle or soft tissue involvement of the patella tendon insertion without obvious bony changes. Often there is only a tendonitis of the patella tendon insertion and inflammation of the deep infrapatellar bursa. Clinically, a young teenager who is quite active in sports will complain of pain and swelling over the tibial tubercle. The condition may be unilateral or bilateral.
On examination, there is an obviously swollen, tender, and occasionally warm area over the tibia tubercle. The radiograph can be normal or show fragmentation of the area of patella tendon insertion. The natural history of untreated Osgood-Schlatter disease is relatively benign, if allowed to heal and complications are avoided. Since unusual stress at a time of rapid growth is occurring, limiting the offending sports activity is usually sufficient to relieve the symptoms. Kneeling and squatting should be limited. Physical therapy is occasionally used if there is unusual hamstring tightness.
A 14-year-old male who is active in sports most of the year presents with bilateral anterior knee pain that is worse in the right knee. An examination reveals tenderness and some swelling at the tibial tubercles.
Which one of the following is true regarding this patient’s condition?
Correct Answer A:
Osgood-Schlatter disease is encountered in patients between 10 and 15 years of age. These patients are often active in sports that involve a lot of jumping. It is thought to be secondary to repetitive microtrauma and traction apophysitis of the tibial tuberosity. Bilateral symptoms are present in 20%-30% of patients. Radiographs may reveal abnormalities, but are rarely indicated in straightforward cases. This condition is usually self-limited, and most patients are able to return to full activity within 2-3 weeks. Treatment includes rest, ice, anti inflammatory medications, a rehabilitation program, and an infrapatellar strap during activities. Casting and corticosteroid injections are not indicated.
A 6-month-old infant presents in the winter with fever, cough, wheezing, tachypnea, and decreased appetite. A chest radiograph shows hyperaeration and streaky perihilar infiltrates bilaterally. You diagnose bronchopneumonia.
Which organism would most likely be causing this child's infection?
Respiratory syncytial virus (RSV) and human metapneumovirus infections cause seasonal lower respiratory tract disease, particularly in infants and young children.
The most recognizable clinical syndromes are bronchiolitis and pneumonia. These illnesses typically begin with upper respiratory symptoms and fever and then progress over several days to dyspnea, cough, and wheezing. Apnea may be the initial symptom of RSV in infants < 6 months. In healthy adults and older children, illness is usually mild and may be inapparent or manifested only as an afebrile common cold.
Disease may be asymptomatic, mild, or severe, including bronchiolitis and pneumonia. Although diagnosis is usually clinical, laboratory diagnosis is readily available. Treatment is supportive.
A 6-year-old male is brought to your office 10 days after the onset of a cough and low-grade fever. On examination, his temperature is 37.9°C (100.2°F), pulse 100 beats/min, respirations 22/min, and O2 saturation 94%. He has diffuse wheezes on auscultation of his chest. His WBC count is 9.8 x 10^9/L with a slight left shift. His C-reactive protein level is mildly elevated and a chest radiograph reveals an interstitial infiltrate.
Which one of the following would be the most appropriate initial therapy?
Correct Answer B:
The most common cause of pneumonia in children ages 5 - 15 is Mycoplasma pneumoniae, which is sensitive to macrolides. The low-grade temperature, borderline WBC count, and lack of a markedly elevated C-reactive protein do not suggest pneumococcal disease. Wheezing is characteristic of both viral and mycoplasmal disease. Respiratory syncytial virus is the most common cause of pneumonia in children age 4 months to 4 years. A 6 year-old is more likely to have mycoplasmal disease.
Antitussives should be avoided as none have been found to be effective in pneumonia.
In early February, you receive a call from your office nurse. Her 5-month-old daughter has been ill for several days. What started as a mild upper respiratory infection has progressed and she now has profuse rhinorrhea, a temperature of 37.9°C (100.2°F), and audible wheezing. In spite of an almost nonstop cough, she does not appear acutely ill.
The organism responsible for this child’s illness is most likely to be:
The most common cause of pneumonia in children age 4 months to 4 years is respiratory syncytial virus. Other viruses may cause pneumonia as well. The peak incidence of respiratory syncytial virus is between 2 and 7 months of age. Wheezing and profuse rhinorrhea are characteristic and the disease typically occurs in mid-winter or early spring epidemics. Parainfluenza 3 typically affects older infants and is not common in winter. Mycoplasma tends to affect older children and children with bacterial illnesses; those infected with this organism generally appear more acutely ill.
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