Pediatric Primary Care (103 page)

E.  Diagnostic tests.

1.  Serum testosterone levels free and total.

2.  Fasting insulin levels.

3.  Ultrasound of ovaries “pearl necklace appearance.”

4.  LH and FSH levels.

5.  DHEA-S.

6.  17 hydroxy-progesterone level.

7.  T3, T4.

8.  Triglycerides and cholesterol levels.

9.  Glucose tolerance.

F.  Differential diagnosis.

1.  Type 2 diabetes.

2.  Pituitary thalamus disorder.

3.  Thyroid disease.

4.  Adrenal cortex disease.

5.  Ovarian dysfunction.

G.  Treatment.

1.  Referral to endocrinologist.

2.  Regulate menses with oral contraceptive. Oral contraceptives such as norgestimate/ethinyl estradiol (Ortho-Cyclen) and norgestimate ethinyl estradio (Ortho Tri-Cyclen) help regulate menses, help with hirsutism, reduce acne, increase bone density, reduce follicular activity, and reduce ovarian and endometrial cancer risk. Oral contraceptives act by suppressing plasma androgens and inhibit ovarian function. If the patient cannot tolerate oral contraceptives, the next therapy would be medroxyprogesterone acetate (Depo Provera) for irregular menses.

3.  Stabilize or reduce body weight/manage lifestyle changes.

4.  Spironolactone (Aldactone) in daily doses of 50-2000 mg orally. Acts by binding at sites of androgen receptors and inhibiting testosterone biosynthesis.

5.  Cosmetic treatment for unwanted hair: either laser or electrolysis.

6.  Acne treated with clindamycin (Cleocin) or other antibacterial medications as indicated.

7.  Insulin resistance may be treated with glucophage (Metformin).

8.  Cholesterol- and triglyceride-lowering drugs as indicated.

H.  Follow up.

1.  Monitor for prevention of long-term health problems such as cardiovascular disease.

2.  Lifestyle modification such as diet and exercise for obesity.

I.  Complications.

1.  Hypertension.

2.  Hyperlipidemia.

3.  Hyperinsulinemia.

4.  Endometrial hyperplasia.

5.  Type 2 diabetes mellitus.

BIBLIOGRAPHY

Alemzadeh R, Wyatt D. Diabetes mellitus in children. In Kleigman R, Behrman, R, et al., eds.
Nelson textbook of pediatrics.
18th ed. Philadelphia, PA: W.B. Saunders; 2007:2404 -2431.

Barron A, & Falsette D. Polycystic ovary syndrome.
Advance for Nurse Practitioners.
2008;16(3):49 -54.

Binns H, & Ariza J. Guidelines help clinicians identify risk factors for overweight in children.
Pediatric Annals.
2004;33:1.

Cohen P, Rogol AD, Deal CL, Rogol A, Dean C, Saenger E, et al. Consensus statement on diagnosis and treatment of children with idiopathic short stature: Summary of the Growth Hormone Research Society.
Journal of Clinical Endocrinology Metabolism.
2008;93(11):4210-4217.

Congeni J, & Miller S. (2002). Supplement and drugs used to enhance athletic performance.
Pediatric Clinics of North America.
2002;49(2):435-461.

Cox D, & Polvado K. Type 2 diabetes in children and adolescents.
Advance for Nurse Practitioner.
2008; 16(11):43-45.

Greydanus DE, & Patel DR. (2010). Sports doping in adolescent: The Faustian conundrum of hors de combat.
Pediatric Clinics of North America.
2010;57(30):729-750.

Gunder L, & Haddow S. Laboratory evaluation of thyroid function.
The Clinical Advisor.
2009;12(12):26-32.

Ho J, Loh C, Pacoud D, & Liung A. Type 1 diabetes mellitus in children and adolescents: Part 1, overview and diagnosis.
Consultant for Pediatricians.
2010;9(2):55-57.

Jenkins R, Adger H. Anabolic steroids. In: Kliegman R, Behman R, et al., ed.
Nelson textbook of pediatrics
,18th ed. Philadelphia, PA: W.B. Saunders; 2007:833-834.

Kaufman F. Type 1 diabetes mellitus.
Pediatric Review.
2003;24:9.

LaFranchi S. Disorders of the thyroid gland. In Saunders. 833-834.

Pinhas-Hamiel O. Type 2 diabetes: Not just for grownups anymore.
Contemporary Pediatrics.
2001;18:1.

Sanfilippo J. Hirsuitism and polycystic ovarian syndrome in Kliegman R, Behman R, et al., eds.
Nelson textbook of pediatrics
, 18th ed. Philadelphia, PA: W.B. Saunders; 2007:2282-2283.

Sanfilippo J. Hirsuitism and polycystic ovarian syndrome. In Kliegman R, Behman R, et al., eds.
Nelson textbook of pediatrics
, 18th ed. Philadelphia, PA: W.B. Saunders; 2007:2316-2337.

Samuels C, & Cohen L. Understanding growth patterns in short stature.
Contemporary Pediatrics.
2001;18:6.

Witchel S, & Finegold D. Endocrinology. In B. Zitelli & H. Davis, eds.
Atlas of pediatric physical diagnosis:
St. Louis: Mosby; 2002.

Wong K, Potter A. Mulbaney S, Russell W, Schlundt D, & Rothman R. Pediatric Endocrinologist's Management of Children with Type 2 Diabetes.
Diabetes Care.
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CHAPTER 30

Musculoskeletal Disorders

Miki M. Patterson

I.  INJURIES: SPRAIN, STRAIN, OVERUSE

A.  Etiology.

1.  Damage or disruption to tendon (attaches muscle to bone), ligament (attaches bone to bone), from overstretching, exertion, repetitive application of excessive forces.

B.  Occurrence.

1.  Wrist, finger, ankle sprains are common among children.

C.  Clinical manifestations.

1.  Limp or pain with extremity or joint use.

2.  Felt tearing or heard a “pop” during activity or with trauma.

D.  Physical findings.

1.  Pain, tenderness to palpation, swelling, discoloration (ecchymosis or erythema).

E.  Diagnostic tests.

1.  Radiograph in two planes to ensure no fracture and to assess bony relationships. May need views of unaffected side to compare ossification centers and normal alignment.

2.  Physical exam: stress joints to varus, valgus, anterior, posterior. If a “give” is felt (e.g., at a knee or ankle joint “opening up”), refer patient to orthopedist. Palpation over physis should be pain free.

F.  Differential diagnosis.

1.  Fracture, dislocation, ligament tears, neurologic deficit, vascular condition.

G.  Treatment.

1.  Protect, rest, ice, compression, elevation (PRICE) and medication for pain as needed:

a.  
Protect:
with splint/brace or relief of weight bearing with crutches.

b.  
Rest:
do not use extremity.

c.  
Ice:
apply ice immediately for 10–20 minutes then every 3–4 hours for the first 24–48 hours.

d.  
Compression:
with ACE wrap; do not pull tightly when wrapping; compression will decrease amount of blood allowed to seep from injured tissues and decrease range of motion at joint.

e.  
Elevation:
above level of heart will decrease swelling accumulating from gravity.

f.  Identify and alter factors that contributed to overuse.

g.  May continue to do activities that do not cause pain.

h.  Pain relievers such as ibuprofen or narcotic, if needed.

H.  Follow up.

1.  Return in 1 week to ensure resolution of majority of pain, swelling, and return of function.

2.  Pain and swelling after 2 weeks requires further workup.

I.  Complications.

1.  Missed fracture.

2.  
Caution:
Salter fractures (through the growth plate) may not be visible on X-ray; if physis is tender, treat as fracture
(
Figure 30–1
).

3.  Compartment syndrome.

4.  Skin breakdown (presents as burning sensation under brace or splint; results from ischemia of tissue; pressure should be relieved immediately).

J.  Education.

1.  Teach family to call immediately for any burning or worsening of pain, neurovascular changes such as paresthesias (numbness or tingling), pallor, paralysis, pulselessness, cyanosis–these 4 Ps are signs of compartment syndrome.

a.  Considered a surgical
emergency.