variety of step 2 questions

[amestramgram]

Hi,

what is the difference in clinical presentation between SCFE and AVN?

in my practice questions I found a 17 yo kid with mental ******ation, who has low grade fever + abd pain. He is afebrile with a HR = 110, RR 22, BP 120/70. He has splinter hemorrhages. He has a 2/6 systolic murmur heard best at the LUSB with a normal S1/S2 + presence of ejection click. There is splenomegaly.

Hgb = 9.1 WBC = 30 000 Plt = 928 000 ESR = 110
U/A = 2+ blood 1+ protein

I was thinking this patient has bacterial endocarditis until I looked at the platelets; is the thrombocytosis still consistent with bacterial endocarditis?

thanks for your help

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[amestramgram]

hi, sorry to be nagging, but does anyone have any ideas?
thanks again!

 

[Vergie]

Yeah I would say subacute bacterial endocarditis. Any hx of dental/cystoscopy or cath insertions?

The big clue for SCFE is it's usually in OBESE children. if they give you a high BMI that's usually a good indication it's SCFE.

Also, if they give you an X-ray, the top of the femoral neck looks like its sliding off the bottom (I think uworld says its like ice cream sliding off a cone).

 

[Valadi]

Hey man,

Legg-Calve-Perthes (AVN) presents with an insidiously developing painful limp in kids around 4-8yrs. Classically, their range of motion will be limited upon ABduction, internal rotation and flexion. X-rays will usually show nothing or epiphyseal lucency; MRI and bone scan may pick up the femoral head necrosis. The worry in these kids is subluxation of the femoral head. And treatment is conservative if they're young and don't show extensive necrosis, otherwise it's surgery.

SCFE is due to the separation of the proximal femur and growth plate. Sex hormones and weight-bearing are implicated in this. So, the typical patient is an obese kid around the time of puberty. This can be acute or subacute in onset and also presents with a painful limp (in both conditions they may complain of pain in the hip or knee). They may have foreshortening of the affected limb, and range of motion is also limited on internal rotation (basically ANYTHING involving the femoral head you get pain on internal rotation, all this does is differentiate it from knee pain or pelvic pain, which would not change). You get the frog-leg lateral xray on these kids and it shows epiphyseal widening and a infero-posterior displacement of the femoral head. Pin-fixation for these kids.

What was the answer to your other question? Although he could have endocarditis, it seems fishy. For your question, though, anytime WBCs go up, you can get a reactive thrombocytosis that jacks up your platelets. There isn't much that sends your WBCs into 30k range, though, except for like C. diff, overt sepsis or staph endocarditis, and cancer, cancer, cancer.

 

[JohnGT]

I'm not sure if it's the right answer, but did you consider that this child may have kawasaki disease? Febrile disease in a child with abdominal pain and signs of vasculities should have kawasaki as part of the differential. Although splinter hemorrhages is a keyword for endocarditis emboli -- it really can just be a manifestation of small vessel inflammation. Further, leukocytosis and thrombocytosis are common findings. The child has some type of valvular pathology, likely insufficiency; although the test point for kawasaki dz is usually association of coronary aneurysms, these kids can also have valvular insufficiency.

 

[turkeyjerky]

I'm not sure if it's the right answer, but did you consider that this child may have kawasaki disease? Febrile disease in a child with abdominal pain and signs of vasculities should have kawasaki as part of the differential. Although splinter hemorrhages is a keyword for endocarditis emboli -- it really can just be a manifestation of small vessel inflammation. Further, leukocytosis and thrombocytosis are common findings. The child has some type of valvular pathology, likely insufficiency; although the test point for kawasaki dz is usually association of coronary aneurysms, these kids can also have valvular insufficiency.

in a 17 year old?

 

[JohnGT]

in a 17 year old?

good point. In the US, the peak prevalence of kawasaki is in children 18-24months.