sobia naeem
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this is a tough one..i,ll go for d.
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| DrS
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Anyone else?
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| achilles
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i'll go for A-head CT scan
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| an
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retinoscopic exam to rule out child abuse...baby too young to roll off on own...?
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| achilles
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this is interesting...we all got different answers...whats the right answer DrS...
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| DrS
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Well the given answer is B. Let me post the given explanation as soon as I get home.
Personally I felt the next appropriate step would be to control the child's seizure with IV benzodiazepines before anything else. And yes retinoscopy is definitely indicated to rule out child abuse but is it possible to perform retinoscopy on a convulsing child?
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| achilles
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good work an !!
well i thought of CT because the child was having seizures and to rule out bilateral subdural hemorrhages ( another sign of child abuse )...
and i think DrS what yu say sounds logical !! what should one do immediately while this baby is having seizures ? should we try to control seizures ?
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| achilles
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i meant, should'nt we try to control seizures ??
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| achilles
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hey DrS, could you check my post on penile injury...i had a question there...hope you can answer it.
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| motivated2
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B... agree w/ an
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| achilles
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DrS, an, motivated2, i have another confusion(i feel i am the most confused guy around here in this forum )...
we do a retinoscopic examination when we suspect shaken baby syndrome, child abuse...is'nt bilateral subdural hemorrhages too another manifestation of shaken baby syndrome and thus child abuse...then why not do a CT scan in this child who is actually having seizures ??
and when the question say's next step...should we not try to control the seizures first... am i missing something here in this question !!
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| an
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achilles, i must say i would put d) as my correct answer...but since drS wanted another one after sobia answered d), my next best answer was b)
a) would not be the next best step...probably the best investigation..
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| DrS
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This was the explanation given guys;
The correct answer is
B. The child's story is worrisome for shaken baby syndrome, in which the symptoms may not correlate with the physical findings. This diagnosis should be considered in any infant presenting with a dissonant history suspicious of child abuse. The child's fontanelles are full, indicative of increased intracranial pressure. A retinoscopic examination will indicate if this is indeed the case, since blurred fundi would suggest increased pressure.
A retinoscopic examination can be done faster than a head CT (choice A). The patient may ultimately need a head CT but the eye examination should be done first.
Ammonia levels (choice C) should be checked if hepatic encephalopathy is a consideration. This is a possibility if Reye syndrome is on the differential. The increased fontanelle pressure leads to a diagnosis of trauma.
Benzodiazepines may be needed (choice D) in the short term to stop the seizure, but it is important to determine the cause of the seizure before intervening.
Because the patient has increased intracranial pressure (suggested by the full fontanelles), a lumbar puncture may cause uncal herniation and should be avoided (choice E).
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| DrS
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Well achilles, i guess this question does seem a bit illogical. I guess in practice the correct sequence of events would be, 1st control the seizure, then do a retinoscopic examination, and finally CT.
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| achilles
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thanks DrS, and i guess you are right in the seqeunce of events but this question was actually good in that how we should be thinking on the exam...if we get a similar question which might want to test us on this concept...then we now know what to do...
keep em coming DrS...
and do you remember we had a discussion on preterm labour not so long ago about if bed rest & hydration is the next step or should we go for toolysis...i got that question during one of my tests in uw and the answer given was bed rest and hydration. the explanation was that hydration causes negative feedback on ADH and alongwith it oxytocin and is thus responsible for reducing uterine contractions in 20% of patients...that patient had a cervical dilatation of 2 cms and was having regular uterine contractions...this patient was early in labour and so bed rest and hydration is the next step...if that patient had more cervical dilatation or quick recent cervical changes then tocolysis is the next step as then hydration is not as effective.
i thought i'll let you know as we had come to the conclusion that tocolysis was the answer in that patient.
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| aimhigh
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I will go with the retinoscopy. We should not simply give the drug without knowing the cause of seizure in pediatrics. For instance, a seizure induced by high fever should be treated with supportive care and drugs for reducing T instead of antiseizure drug.
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| achilles
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aimhigh that makes sense too...so its retinoscopy first and then if shaken baby syndrome is thought of then the child should be sent for CT scan of the head...and to rule out other causes also.
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| AAAAA
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B is correct.
You have to think from the NBMA the examiner's prespective.
This question raises the awareness if child abuse in America !
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| AAAAA
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B is correct.
You have to think from the NBMA the examiner's prespective.
This question raises the awareness if child abuse in America !
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| yasmeen
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BUT THE NEXT MOST APPROPRIATE STEP IS CONTROL OF SEIZERS BY BENZODIAZEPINES SO D IS RIGHT
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| DrS
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I guess the controversy continues!
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| AAAAA
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The answer is NOT D. You never give benzo to a pedi patient with clonic tonic seizure patient
It is B
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| achilles
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yup...its B.
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| study_ing
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"You never give benzo to a pedi patient with clonic tonic seizure patient "
cud u explain y..i tot the treatment for a siezure in the ER was BDZ...
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