Case records of Wright State University: an unresponsive five-year-old boy.
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Adolescent↗
Biomedical subjects
J I Singer
Publications and source records attributed to J I Singer.
Occult bacteremia and septicemia in the febrile child younger than two years.
The literature on the assessment and the preferred treatment strategies for children without a focus of infection is reviewed. Opinions are offered regarding the diagnostic evaluation and therapeutic interventions for febrile infants and children who are at risk for occult bacteremia or sepsis. Clinicians are encouraged to consider the proposed strategies but not to supplant their prevailing practice.
Bacteremia↗
Retropharyngeal abscess in an afebrile child.
A case of retropharyngeal abscess in a child is reported. The patient was nontoxic appearing, afebrile, and had minimal symptoms. The case is used to highlight the high index of suspicion that may be necessary to diagnose the condition. Diagnostic approaches, emergency treatment, and disposition of patients are discussed.
Abscess↗
Use of acyclovir in varicella.
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Acyclovir↗
Acute testicular pain: Henoch-Schönlein purpura versus testicular torsion.
A skilled examiner may not be able to exclude testicular torsion by physical examination maneuvers in a patient who presents with acute scrotal pain. Diagnostic adjunctive studies may be of assistance. However, if a diagnosis cannot be established with certainty, surgical exploration is warranted. Patients with Henoch-Schönlein purpura who present with a vascular eruption on the scrotum, lack a rash elsewhere, and have no arthritis or hematuria are likely to be explored.
Acute Disease↗
The wheezer that wasn't.
The expression of cardiac dysfunction in pediatric patients with myocarditis may not be conspicuous. While older children with myocarditis may abruptly present with pleuritic or angina-like pain, infants and toddlers with fulminant disease are unable to verbalize such complaints. Cardiac compromise in preverbal children may only be inferred from variable examination findings that include gallop rhythm, tachycardia, malignant dysrhythmias, murmur, rub, and signs of congestive heart failure. The emergency physician is likely to overlook a cardiac origin for wheezing in a child with a past medical history of asthma. Therapeutic modalities chosen for reactive airway disease may adversely influence the outcome of a patient with myocarditis.
Asthma↗
A fatal case of colic.
The potential causes of excessive, prolonged crying in early infancy represent a broad range of conditions. The underlying etiology causing an acute episode of crying may not be recognized in a single emergency department encounter. An adverse outcome may result when an infant with unexplained crying is discharged with a diagnosis of colic.
Child Abuse↗
An aseptic meningitis picture from incipient brain abscess.
A preadolescent with headache and stiff neck presented for emergency department care. The presumptive diagnosis of viral meningitis was entertained on the basis of clinical examination and cerebrospinal fluid analysis. Events subsequent to his release from the department formed the stimulus for this report. It is apparent that patients with complicated sinusitis may present with a constellation of findings consistent with viral meningitis.
Brain Abscess↗
Evaluation of the patient with neck complaints following tonsillectomy or adenoidectomy.
The emergency physician should be cognizant of the potential postoperative complications of tonsillectomy or adenoidectomy. Two unusual cases are presented to illustrate the differential diagnosis of the postoperative complaint of neck stiffness.
Adenoidectomy↗
Erroneous diagnosis within the cranial vault.
The majority of pediatric neoplasias of the brain are midline growths in the posterior fossa. These mass lesions lead to obstruction of cerebrospinal fluid circulation and cause increased intracranial pressure. Affected children typically present with insidious complaints of headache and vomiting. Ataxia, cranial nerve palsies, or pyramidal tract signs may be present at the time the diagnosis is entertained. In the reports describing pathognomonic clinical features of posterior fossa tumors, an accelerated presentation with minimal prodromal events has not been emphasized. This report details the case of a child with a cerebellar medulloblastoma who presented with abrupt onset of fever, nuchal rigidity, and altered mental status. Emergency department misdiagnosis occurred.
Acute Disease↗
Grunting respirations: chest or abdominal pathology?
A large percentage of misdiagnosed appendicitis cases occur during childhood. Misdiagnosed patients have increased morbidity and mortality from the diagnostic delay. The patients excused from an emergency facility who are ultimately shown to suffer from appendicitis have higher rates of perforation with attendant abscess formation, peritonitis, sepsis, and potential death. The patients with misdiagnosed appendicitis are young and likely to have atypical signs and symptoms. Grunting respirations incorrectly attributed to respiratory infection may serve as a pathway for a misdiagnosed case of appendicitis.
Adolescent↗
Vertebrobasilar occlusion following minor trauma in an 8-year-old boy.
An 8-year-old boy developed seizures and coma 2 days after a trivial bicycle accident. Computed tomography failed to show pathology. Magnetic resonance imaging of the head showed infarction of the pons and right cerebellum. Angiography showed occlusion of the right vertebral and basilar arteries. Minor traumatic injuries to the cervical spine may result in vertebrobasilar occlusion. The neurologic manifestations of this disorder and emergency department diagnosis and management are discussed.
Bicycling↗
Interstate pedestrian crossing: a form of self-destructive behavior?
Emotional conflicts, malassociation with peers, and inadequate family support are not the emergency physician's primary considerations when attending a severely traumatized child. This report makes an appeal for the clinician to determine the sequence of events that preceded the trauma. Attempts should be made to distinguish between intentional and accidental trauma by viewing the event, not in isolation, but rather in the context of potential environmental stress affecting the child and family. Among the multidisciplinary coalition we forge to provide ongoing care for the trauma patient, there should be a mental health specialist. Exploration for family discord, escalating stress, and suicidal ideation should become central themes for emergency physicians who treat traumatized children.
Accidents, Traffic↗
Postural guarding and hypertension as initial manifestations of Guillain-Barré syndrome.
A child without any prodromal events presented with incapacitating, symmetrical limb pain intensified by any movement. He lacked objective motor weakness or reflex changes. A provisional diagnosis of Guillain-Barré syndrome was not entertained despite sequential examinations that further documented dysesthesia, postural guarding, and hypertension. The clinician must consider Guillain-Barré syndrome as a cause for self-imposed immobilization associated with autonomic dysfunction.
Child↗
Management strategy for penetrating oropharyngeal injury.
Direct force applied to an object held in the mouth may cause either superficial or penetrating injury within the oropharynx. The natural course for a majority of these injuries is spontaneous healing. Penetrating trauma in the parapharyngeal space may cause life-threatening vascular injuries. Violation of the retropharyngeal space may lead to dissecting emphysema or mediastinitis. Knowledge of these infrequent but serious sequelae complicates emergency department management decisions.
Child, Preschool↗
Unintentional trauma to the penis.
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Anastomosis, Surgical↗
Epiglottitis at the extremes of age.
Epiglottitis may occur at any age. The typical presentation in the young child and young adult is well known, but the presentation in patients at the extremes of age has not been characterized. At our locale, from 1974 to 1984, 19 children 24 months of age or less and, from 1979 to 1984, 9 adults 50 years of age or greater with epiglottitis were seen in the emergency department. In the infantile group, rapidly progressive interference with swallowing, vocalization, and respiration was encountered in less than half the patients. Symptoms were often prolonged before parents sought attention for their child. No preference was shown for maintenance of the upright position while at rest, as recumbency did not promote stridor or initiate respiratory distress. Respiratory complaints were common and included cough, tachypnea, and retractions. Drooling or retention of pharyngeal secretions was uncommon. The adult population had a history of symptoms that spanned several days. Extreme sore throat, pooling of oral secretions, muffled voice, and elevated temperature were uncommon. Dysphagia and mild respiratory complaints were frequent. Upper airway obstruction did occur. At both extremes of age, exceptions to the classic clinical pattern of epiglottitis occurred with significant frequency. Despite this, diagnosis and management in the emergency department were appropriate in most cases.
Adult↗