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Terms in this set (117)

Salicylates have analgesic and antipyretic properties when used systemically, and keratolytic properties when used topically. This patient has developed salicylate intoxication secondary to absorption of large amounts of salicylate through the skin. Many skin conditions that are characterized by hyperkeratosis are treated with topical preparations that contain a certain amount of salicylic acid (ranging from 1 to 40%, depending on the indication). They should never be used in children, however, because the surface-to-volume ratio is very large and even a relatively small amount absorbed through a large surface area will result in significant systemic levels. Even in adults, preparations with a significant amount of salicylic acid should be used cautiously, and either for a very limited time or only on certain body surface areas at a time. The clinical presentation and physical findings will vary with the dose of salicylates ingested. Vomiting, hyperpnea, fever, lethargy, and mental confusion are seen in mild salicylate poisoning. Convulsions, coma, and respiratory and cardiovascular collapse are seen in severe salicylate poisoning. Hyperventilation, dehydration, bleeding disorders, seizures, and coma are seen in chronic salicylate ingestion. Arterial blood gas analysis will show metabolic acidosis with respiratory compensation in children and a respiratory alkalosis alone in adolescents. To enhance the excretion of salicylate, the intravenous route should be used to administer bicarbonate and raise the urine pH to 7.0-7.5. If the salicylate level is greater than 100 mg/dL, hemodialysis may be indicated.
This patient has the typical presentation of gastroesophageal reflux. Gastroesophageal reflux occurs with a reduction in lower esophageal sphincter pressure, inappropriate lower esophageal sphincter relaxation, hiatal hernia, or delayed gastric emptying. This condition is common in the pediatric population, particularly in infants with developmental delay or cerebral palsy. It is a minor condition and of no consequence (so-called "functional gastroesophageal reflux"); patients present with a wide array of symptoms. Some form of spitting up and even forceful vomiting are common. Apnea can be a presenting sign. Reflux into the hypopharynx triggers laryngospasm and subsequent obstructive apnea. Chronic cough and wheezing may signal aspiration. Some patients exhibit poor weight gain and failure to thrive. Sandifer syndrome presents with gastroesophageal reflux and opistotonus, presumably to avoid aspiration or decrease pain. A pH probe is the standard method that is used for diagnosing gastroesophageal reflux. Other imaging studies include technetium scanning and barium swallow. Initial therapy consists of antireflux measures, such as elevating the head of the bed and thickening of feeds. If this fails to provide relief of symptoms, medical management with antacids, prokinetics, H2-receptor blockers, and proton pump inhibitors should be attempted. Failure of medical management may require surgical correction with a Nissen fundoplication. Most patients, however, have resolution of symptoms without any treatment.
Increased hydrostatic pressure in splanchnic capillary beds. Ascites often occurs in patients who have cirrhosis and other forms of severe liver disease and is usually noticed by the patient because of abdominal swelling. Shortness of breath may occur because the diaphragm is elevated when the accumulation of fluid becomes more pronounced. Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed.

Elevated serum levels of epinephrine and norepinephrine occur as a result of increased central sympathetic outflow, in patients who have cirrhosis and ascites.

The increased sympathetic output leads to decreased natriuresis by activation of the renin-angiotensin system and diminished sensitivity to atrial natriuretic peptide.

Interstitial fluid often weeps freely from the surface of the cirrhotic liver because of distortion and obstruction of hepatic lymphatics with resultant decreased hepatic flow. This interstitial fluid has a high protein concentration because the endothelial lining of the hepatic sinusoids is discontinuous. The entry of protein-rich interstitial fluid into the peritoneal cavity may account for the high protein concentration present in the ascitic fluid of some patients. The high protein content of the interstitial fluid results in fluid retention and an increase in plasma volume.

Ascites is the accumulation of fluid in the peritoneal cavity; the causes are usually related to cirrhosis. With cirrhosis the liver undergoes loss of functional cells, causing increased portal pressures and increased pressures in the gastric and splenic venous systems. Other causes of ascites include hypoalbuminemia (generalized swelling caused by poor oncotic pressure in the cell with resultant cellular leakage) and neoplasms such as ovarian cancer with malignant accumulation of fluid in the peritoneal cavity.
Rotavirus. Causes of acute and chronic diarrhea are age-dependent. Acute diarrhea is almost always infectious, with gastroenteritis the most common cause in any age group. Food poisoning, systemic infections, parasitic infections, and antibiotics are other causes. Viral agents are the most common cause of acute diarrhea in children, and rotavirus is the most common viral cause of diarrhea in the winter. Enteric adenovirus and Norwalk virus are also common causes of diarrhea. Bacterial causes include E. coli, Salmonella, Shigella, Campylobacter, Yersinia, and Clostridium. Parasitic causes include Entamoebahistolytica, Giardia, and Cryptosporidium. Clinically, rotavirus infection presents with watery diarrhea that can last up to 7 to 10 days. It may be accompanied by 3 to 4 days of vomiting. Fever may be present. The stool may be positive for occult blood. There is no abdominal tenderness associated with rotavirus infection.

Viruses account for about 70 to 80% of episodes of acute gastroenteritis in children, with rotavirus being the most common identifiable cause of gastroenteritis in children. Rotavirus is commonly spread in the daycare setting. Rotavirus is ubiquitous and almost all children are affected by 3 years of age. Spread is via fecal-oral route, but recent studies have suggested that rotavirus may be spread by respiratory droplets. Treatment is conservative, with maintenance of hydration being the most important element of care. Supporting the patient's hydration status until the virus is spontaneously cleared is the management of choice. Rotavirus infection can cause simultaneous nausea, vomiting, and diarrhea along with a low grade fever that may be caused by the dehydration that rapidly occurs. Strict hand washing techniques may help to limit the spread of this virulent pathogen.

Diarrhea is defined as an increased stool output, with excess loss of fluid and electrolytes. It can be classified as acute or chronic. Several mechanisms exist that cause diarrhea, of which more than one may be present: 1. secretory: decreased absorption, increased secretion. 2. osmotic: maldigestion, transport defects, ingestion of unabsorbable solute. 3. increased motility: decreased transit time. 4. decreased surface area: inflammation, decreased colonic absorption, increased motility.
An 8-year-old girl is brought to the office because she has been complaining of frequent abdominal pain. The episodes occur every several days, show no particular pattern, and resolve without treatment within 10-15 minutes. During the episodes, the child has to lie down and bring her legs up to her chest for relief. The parents state that she started having this problem approximately a year ago, and they believed it was related to her diet. After trying to restrict various kinds of food with no effect, they decided to have her examined. Her bowel movements are regular. She has no significant past medical history and takes no medication on a regular basis. She has an older brother who is in excellent health. The mother tells you that she loves school and is a very good student. She is very popular among her friends and has no problems in social relationships. Of interest, they immigrated to the United States 3 years earlier and have moved 3 times since then for work. She did not seem to have any trouble adjusting to that situation. They will be moving to another city again in 6 months. On physical examination the girl is in no acute distress. She is in the 90th percentile for height and weight. Vital signs are within normal limits, as is a complete blood count with white blood cell differential. Her abdomen is not distended and is soft and nontender to palpation. Plain abdominal films show no abnormalities. Which of the following patient intervention/patient education scenarios should be pursued?
Adult respiratory distress syndrome due to circulating phospholipase. Acute pancreatitis is suggested by this patient's severe epigastric pain, which radiates to his back and is accompanied by nausea and vomiting. The diagnosis is confirmed by demonstrating serum elevation of the pancreatic enzymes amylase and lipase. More than 80% of the hospital admissions for acute pancreatitis are related to either biliary tract disease (typically with a stone lodging in the duct system below the entry of the pancreatic duct) or alcoholism, and this patient admits to recent active drinking. Acute pancreatitis is a very dangerous disease, not only because it potentially destroys large areas of pancreatic tissue, but also because the destruction of the exocrine gland tissues potentially releases a great many enzymatically or physiologically active substances into the bloodstream. Among the released substances is phospholipase, which circulates through the bloodstream and damages the alveolar capillary membranes in the lungs, predisposing for adult respiratory distress syndrome (ARDS). Acute pancreatitis leads to production of inflammatory mediators that can lead to damage of the alveolocapillary membrane of the lung, which can lead to destruction of the pneumocytes and decrease in the production of surfactant. This leads to increased surface tension in the lung, along with inadequate oxygenation. Bilateral lung infiltrates and potentially ARDS can develop. These patients may require mechanical ventilation if ARDS develops.
This patient has intussusception, which occurs when a portion of the gastrointestinal tract slips or telescopes into the portion just distal to it. A barium enema is diagnostic and therapeutic, and is the initial diagnostic and treatment of choice for symptoms of less than 48 hours' duration. Most intussusceptions are ileocecal, and most have no known cause. Intussusception is most commonly seen in children age 5-24 months (range, 3 months to 6 years) most commonly occurring in the first year of life. Acute onset of cramping, colicky abdominal pain is the hallmark of intussusception. Patients may have vomiting. As the obstruction progresses, the patient may develop fever and lethargy. The classic currant jelly stool (stool with red blood and mucus) is a late finding. Passing a stool may temporarily relieve pain. A sausage-shaped mass may be palpated in the right upper quadrant on physical examination. If the obstruction becomes complete, there is abdominal distention and shock may ensue. A coil-spring sign is seen as the barium fills the obstruction. Air enemas may also diagnose and treat with greater safety. Ultrasound may be helpful in establishing the diagnosis. Intussusception is an emergency and should be reduced as quickly as possible. Hydrostatic reduction with air or contrast barium enema is successful approximately 50% of the time for symptoms lasting longer than 48 hours, and 75-80% for symptoms lasting less than 48 hours. It should not be done in the face of prolonged intussusception, peritonitis, or perforation. Surgery is recommended in those cases or after failure of hydrostatic reduction. Untreated intussusception is almost uniformly fatal because of bowel perforation and peritonitis.