I Walk Like a Monster, Mom!

Patient Presentation
A 4-year-old male came to clinic for a new onset painful limp. He awoke cranky and over the morning he complained of pain in his left leg, possibly in his knee.
His mother looked at his legs twice in the morning and could not find any problems. He was otherwise playful and only complained when he walked. Over the morning she noticed that he began to limp. Around noon, he said, “I walk like a monster!” His mother said he could not run and had a significant left sided limp.
After his afternoon nap, he refused to walk and complained of any motion of his left leg and was brought to the clinic.
The past medical history and family history are negative.
The review of systems revealed no fevers, concurrent or significant illnesses. He is in daycare. He had not received any pain medication. The night before he did slip onto a hardwood floor, but his mother said it was a “normal fall.”The pertinent physical exam revealed an afebrile boy who did not want his left leg moved. He could not pinpoint the pain. His skin, abdomen, back and genitourinary systems were normal. He had shoddy anterior cervical and inguinal adenopathy.
He held his left leg slightly abducted at the hip and flexed at the knee. He had decreased internal rotation and flexion at the left hip. His left knee, ankle and foot and right lower extremity were normal.
The laboratory evaluation included a complete blood count which was normal with a white blood cell count of 8.4 X 1000/mm2and normal differential. His erythrocyte sedimentation rate was 8 mm/hr and his C-reactive protein was < 0.5 mg/dl.
The radiologic evaluation included AP and frog-leg plain radiographs of the pelvis and upper extremity which were normal.
The diagnosis of transient synovitis was made. The patient was sent home with recommendations to receive scheduled ibuprofen for 5 days and to monitor his symptoms. The patient’s clinical course showed slow improvement with no pain on day 2, no limp with walking on day 4, and no limp with running on day 5.


Figure 37 – AP and frog-leg radiographs of the pelvis show no evidence of fracture, avascular necrosis, or slipped capital femoral epiphysis. The only remarkable finding is a subtle one – the left femoral head on both views is slightly more displaced laterally than the right femoral head, suggesting the presence of a left hip effusion. Note that radiographs are extremely insensitive for detecting hip effusions, and a hip effusion cannot be excluded on a normal radiograph. The proper radiology test to evaluate for a hip effusion is a hip ultrasound.

Discussion
Transient synovitis of the hip (i.e. toxic synovitis) is a non-specific inflammation of the hip of unknown cause, although it frequently occurs after a previous bacterial or viral infection. It is self-limited and generally resolves in 1 week.
It often presents with pain and limp. The pain can be referred to the knee and/or thigh and the child may refuse to bear weight. Transient synovitis is a diagnosis of exclusion, particularly of higher morbidity diagnoses such as septic arthritis, osteomyelitis, Legg-Calvé-Perthes disease, juvenile rheumatoid arthritis, slipped capital femoral epiphysis and malignancies.
On physical examination the child often does not like to have the hip and/or knee moved. There is resistance/restriction to internal rotation of the hip and abduction. The laboratory tests are generally normal with the erythrocyte sedimentation rate sometimes being slightly elevated.
Treatment includes rest and non-steroidal, anti-inflammatory medication. Sometimes aspiration of the joint is necessary to rule out a septic arthritis and to relieve pain. If the child fails to improve then other diagnoses must be re-considered and appropriately evaluated.

Learning Point
Limps in children are a common complaint. The potential causes can be narrowed down based upon a good history: acute vs. chronic, painful vs. painless, and age.
Acute and painful limps are more likely due to trauma or infection; chronic limps are likely to be juvenile rheumatoid arthritis or due to causes of painless limps. The younger the child, generally the more cause for concern and the earlier the patient should be evaluated.
In younger children, soft tissue injuries, fractures and transient synovitis are some of the most common causes of limp.
As children get older, Legg-Calvé-Perthes disease and slipped capital femoral epiphysis also are added to the causes.
Pinpointing the location of the problem sometimes is difficult and a good physical examination can be very helpful and also can narrow the differential diagnosis. It is important to remember that pain can be referred from other areas of the body causing a limp (e.g. adenitis, genitourinary system).
Evaluation depends on the differential but often a complete blood count, erythrocyte sedimentation rate and/or C-reactive protein, and plain radiographs begin the evaluation.

Important historical information includes:

  • Patient age
  • Acute or chronic onset
  • Constant or intermittant limp – occurs at various times of the day
  • Affects the child’s daily activities
  • Painful or painless limp
  • Other associated symptoms
  • Loss of developmental milestones
  • History of trauma
  • History of previous or concurrent illnesses

Common Causes of Painful and Painless Limp

  • Painful

    • Infection – transient synovitis, septic arthritis, diskitis, osteomyelitis, adenitis, myositis, bursitis
    • Juvenile rheumatoid arthritis
    • Malignancy – leukemia, primary bone or soft tissue tumor, metastatic disease
    • Osteochondritis – Legg-Calvé-Perthes disease (acute), Osgood-Schlatter, osteochondritis dissecans, etc.
    • Referred pain – back, abdomen, genitourinary system
    • Trauma – fracture, e.g. toddler’s fracture, soft tissue injury, child abuse, slipped capital femoral epiphysis
    • Other – e.g. Caffey’s disease, sickle cell pain crisis, scurvy, porphyria
  • Painless

    • Developmental dysplasia of hip
    • Leg length discrepency
    • Legg-Calvé-Perthes disease (chronic)
    • Neuromuscular problems – e.g. cerebral palsy, muscular dystrophy, poliomyelitis
    • Rickets

Common Causes of Painful Limp by Age

  • Age 1-3 Years
    • Transient synovitis
    • Septic arthritis
    • Trauma – fracture, soft tissue injury
    • Diskitis
    • Juvenile rheumatoid arthritis
  • Age 4-10 years
    • Transient synovitis
    • Septic arthritis
    • Trauma – fracture, soft tissue injury
    • Diskitis
    • Osteomyelitis
    • Juvenile rheumatoid arthritis
    • Legg-Calvé-Perthes disease (acute)
    • Malignancy
    • Sickle cell pain crisis
  • Age 11+ Years
    • Transient synovitis
    • Septic arthritis
    • Trauma – fracture, soft tissue injury
    • Osgood-Schlatter
    • Osteomyelitis
    • Juvenile rheumatoid arthritis
    • Malignancy
    • Slipped capital femoral epiphysis
    • Sickle cell pain crisis

Questions for Further Discussion
1. What are the indications for nuclear medicine or magnetic resonance imaging for possible septic arthritis or osteomyelitis?
2. What organisms commonly cause septic arthritis or osteomyelitis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MEDLINEplus for this topic: Hip Injuries and Disorders

To view current news articles on this topic check Google News.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2436-7.

Grover G. Evaluation of Limp, in Pediatrics A Primary Care Approach, Berkowitz CD. ed. W.B. Saunders Co. Philadelphia PA. 1996:320-324.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:273.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    April 24, 2006

  • When Should the Anterior Fontanelle Close?

    Patient Presentation
    A 1.5-month old male came to clinic with symptoms of an upper respiratory infection. He was noted to have a 3 millimeter anterior fontanelle opening.
    The past medical history was negative.
    The family history revealed no birth defect, congenital or neurological abnormalities.
    The review of systems showed normal vision, hearing and development by his parents report.
    The pertinent physical exam showed a well-developed, playful and appropriately interactive male with normal vital signs. His weight and length were 75%. His head circumference was 95% which was slightly increased from birth and his two week appointment when it was 90%.
    The skull was normally shaped and there was no ridging of any suture line. His posterior fontanelle was closed. He had clear rhinorrhea. His neurological examination was normal. No other potential congenital anomalies were observed.
    The radiologic evaluation of plain radiographs of the skull showed no craniosynostosis.
    The diagnosis of upper respiratory infection with a small anterior fontanelle was made. He was to return for his regular health maintenance visits for follow-up.


    Figure 36 -AP and lateral radiographs of the skull show the coronal, lambdoid and sagittal sutures to be patent. There is no evidence of craniosynostosis.

    Discussion
    The skull is formed from 3 main bones.
    The anterior frontal bone has two halves which are divided by the frontal or metopic suture. The medial parietal bone has its two halves divided by the sagittal suture.
    The posterior occipital bone posteriorly has its two halves divided by the superior median suture.
    Between the frontal and parietal bones lies the coronal suture. Between the parietal bone and the occipital bone lies the lamboid suture.
    Anteriorly, at the confluence of the metopic, coronal and sagittal sutures is the anterior fontanelle. Posteriorly, at the confluence of the superior median, lamboid and sagittal sutures is the posterior fontanelle.

    The sutures are palpated as slightly depressed linear concavities. The fontanelles are felt as soft circle-like concavities. The fontanelles should be assessed with the infant in the upright position, and in this baseline position they will be positioned slightly concave to the surrounding bones.
    This baseline position will be elevated normally during vagal maneuvers such as coughing, crying or emesis.
    A fontanelle position that is very concave may indicate dehydration. A fontanelle position that is even with, or elevated above, the surrounding bones may indicate a serious neurological problem such as meningitis or hemorrhage. Other causes of an elevated anterior fontanelle are Vitamin A or lead toxicity, sinus thrombosis or a brain tumor.
    Pulsations felt in the fontanelles generally are normal and reflect the peripheral pulse.

    The bones and suture lines may be overriding each other after birth because of molding of the skull through the birth process. This molding generally resolves in the first 2 days.
    Suture lines felt to be prominently ridged may be an indication of craniosynostosis or premature closure of the sutures. This results in an abnormally shaped head as the skull grows perpendicular to the suture line. A variety of abnormally shaped heads may result.
    Craniosynosis can be part of a genetic syndrome or it can be sporadic. Surgical treatment may be necessary to re-open the suture line and allow normal brain growth.

    Learning Point

    The posterior fontanelle generally measures 1-2 centimeters at its greatest diameter at birth and generally closes by 2 months of age.

    The anterior fontanelle generally measures between 4-6 centimeters at its greatest diameter at birth and may be larger in the first 6-9 months of life. It generally closes between 4-26 months of age. A larger fontanelle may indicate hypothyroidism.
    A small anterior fontanelle in a child with normal development and no evidence of craniosynostosis is most likely due to normal variation. As with all children, it is important to follow them over time.

    Questions for Further Discussion
    1. What the are the indications for plain radiographs versus computed tomography for the evaluation of craniosynostosis?
    2. What are the possible treatments for positional plagiocephaly?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MEDLINEplus for these topics: Infant and Newborn Care and Facial Injuries and Disorders.

    To view current news articles on this topic check Google News.

    Bates B. A Guide to Physical Examination. J.B. Lippincott Company, Philadelpha, PA. Third Edit. 1983:465-67.

    Barness L. Manual of Pediatric Physical Diagnosis. New York Medical Publishers, Chicago IL. 2nd Edit. 1961:47.

    Adeyemo AA, Olowu JA, Omotade OO. Fontanelle sizes in term neonates in Ibadan, Nigeria. West Afr J. Med. 1999:18;55-9.

    ACGME Competencies Highlighted by Case

  • Patient Care
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    April 17, 2006

  • What are the Presentations of Epstein Barr Virus Infections?

    Patient Presentation
    A 19-year-old female came to clinic with a two week history of becoming progressively more tired and sleeping more.
    That day, one of her college professors, pulled her aside after class and asked if something was wrong because the professor felt that she was not acting right.
    She said that she had just been more tired, but had been going to school. She said that she has been eating and drinking but not as much. She also said that she has had some problems concentrating and it had been taking her much longer to finish her homework.
    With further questioning, she related taking an examination 2 days prior, after which she walked out of the room, and when she looked back at the door she couldn’t remember what she had been doing in the room.
    She also stated that sometimes things seem ‘strange’ to her. She said that everyday items would appear distorted such that they are much larger or much smaller than they should be.
    The past medical history and family history was negative including psychiatric disease.
    The review of systems was negative for fever, chills, cough, pain, sore throat, weight loss, urinary symptoms or rashes.
    The pertinent physical exam showed a tired appearing female with normal weight. She had minimal pharyngeal redness. She hadhas 3 posterior cervical lymph nodes bilaterally that were 1 – 1.5 centimeters in size . She has had shoddy anterior cervical and inguinal lymph nodes.
    She had no supraclavicular, axillary or popliteal lymph nodes. There was no hepatomegaly, but a spleen tip was palpable laterally. She had no rash. Her mental status examination was normal, but she stated that she felt like it was taking a great deal of effort to remember the items asked or to do the mathematical problems.
    The laboratory evaluation included a complete blood count which showed a white blood cell count of 17,000/mm2 with a predominance of lymphocytes. Her erythrocyte sedimentation rate was 25 mm/hr. Her liver enzymes and a rapid strep test were normal. Her heterophil monospot was positive.
    The diagnosis of infectious mononucleosis or Epstein Barr virus infection (EBV infection) was made. She was counseled as to the natural history of the viral infection and was treated with supportive care and her activity was restricted because of the splenomegaly.
    She slowly improved over the next 6 weeks.

    Discussion
    Epstein Barr virus infection (EBV infection) is viral infection spread mainly through saliva. It is only found in humans.The incubation period is 30-50 days and usually has a 3-5 day prodrome of malaise, fatigue, headache, nausea or abdominal pain. Primary infection occurs in the 0-3 years age group for those with low socioeconomic status or in high population densities. In developed countries, it has two peaks for presentation: before age 5 and in adolescents.

    Heterophil antibodies (detected by monospot test) may not appear for up to 3 weeks after the prodrome making the monospot test falsely negative often . False positive heterophil tests can be caused by serum sickness or neoplastic processes.
    EBV serology is usually done for patients whose heterophil test is negative but there is a strong clinical suspicion.

    Patients with EBV should be warned to avoid contact with immunocompromised persons and to not share saliva with other persons through intimate contact, toothbrushes, glasses, etc. They should also not donate blood.

    Most patient recover within a few weeks. Fatigue may take months to recover from though. splenomegaly may persist for weeks after primary infection.

    Learning Point
    Clinical presentations of EBV infections include:

    • Subclinical – may have minor symptoms of rhinorrhea, diarrhea and/or fever.
    • Infectious Mononucleosis – also called glandular fever. This is classically seen with fatigue, fever, lymphadenopathy, malaise, exudative pharyngitis, and splenomegaly. The triad of fever, sore throat and posterior cervical adenopathy occurs in more than 80% of patients.
    • Airway obstruction – secondary to lymphoid hyperplasia
    • Rash – morbilliform usually seen after ampicillin or amoxicillin but also urticaria, hemorrhagic, bullous or scarletinoform rashes.
    • Chronic fatigue syndrome – is not specifically related to EBV infection but a small group of patients with persistent symptoms have abnormal serologic tests for EBV and other viruses.
    • Dehydration
    • Hematologic problems – aplastic anemia, hemolytic anemia, hemolytic-uremic syndrome
    • Inflammatory problems – hepatitis, genital ulcerative disease, mesenteric adenitis, myocarditis, orchitis, pancreatitis, periorbital edema
    • Nervous system infection – aseptic meningitis, Bell’s palsy, Guillian-Barre syndrome, meningoencephalitis, peripheral or optic neuritis
    • Oncologic/lymphoproliferative problems – Burkitt’s lymphoma, lymphoma and Hodgkin’s lymphoma, nasopharyngeal carcinoma, x-linked lymphoproliferative syndrome
    • Psychiatric symptoms – sometimes called the “Alice in Wonderland” effect after the similar descriptions in the Lewis Carroll’s book. People have distorted space, time and body image as presented in this case.
    • Splenic rupture – occurs in 1/1000 patients with 50% of these being spontaneous rupture
    • Streptococcal pharyngitis – 5-25% of patients have a concomitant infection

    Questions for Further Discussion
    1. When can a patient with splenomegaly be returned to normal activity?
    2. What are the indications for corticosteroids for patients with EBV infection?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MEDLINEplus for this topic: Infectious Mononucleosis
    and at Pediatric Common Questions, Quick Answers for this topic: Mononucleosis.

    To view current news articles on this topic check Google News.

    Cooperman SM. “Alice in Wonderland” syndrome as a presenting symptom of infectious mononucleosis in children: a description of three affected young people. Clin Pediatr. 1977 Feb;16(2):143-6.

    Ousterhoudt KC. Epstein Barr Infections, In M. William Schwartz (ed.) 5 Minute Pediatric Consult. Lippincott Williams & Wilkins; 3rd edition. 2000:356-57.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1035-1039.

    American Academy of Pediatrics. Epstein-Barr Virus Infections, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;271-275.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    April 10, 2006

  • What is the Female Athlete Triad?

    Patient Presentation
    A 19-year-old female came to clinic when she was home from college over Thanksgiving break. She complained of several months duration of bilateral shin pain. She denied acute injury
    She was a dance performance major and said the pain persisted for several hours after rehearsal with occasional pain in the morning.
    The past medical history reveals depression and she was currently taking anti-depressive medication.
    The pertinent physical exam revealed a well-appearing female. She was 5 foot 6 inches tall, and weighed123 pounds (body mass index = 20.0). HEENT and skin were normal. She had full range of motion in hips, knees and ankles. There was significant tenderness to palpation along the entire medial aspect of both tibiae.
    There was less discomfort over the anterior tibiae with normal strength with ankle dorsiflexion and plantar flexion. Lumbosacral spine was normal and there was normal sensation in the lower extremities.
    The radiologic evaluation revealed no abnormalities or fractures on bilateral anterio-posterior and oblique tibia-fibula radiographs.
    Furthur history revealed that the patient has been being pressured from her instructors to lose weight. She described binge eating and using laxatives with a >15 pound weight gain since the beginning of the academic year. She has no vomiting behaviors.
    She has dance classes several times/day with additional workouts.
    She has been in counseling for her depression for 15 months but has not told her counselor about the pressure from her instructors, nor the disordered eating.
    She has had amenorrhea for the past 6 months with a previous history of normal menses.
    The physician suspected the diagnoses of medial tibial stress syndrome and female athlete triad. He recommended long-leg pneumatic splints, non-steroidal anti-inflammatory medication and limiting her activities (which she said she could not do because of immediate performance demands).
    He also recommended continued counseling with her current therapist with disclosure of the disordered eating and feelings of pressure from instructors. He also recommended discussing these issues with her instructors.
    Additionally, she was instructed to not restrict her diet, take a calcium supplement and was referred to a nutritionist. A bone mineral density test performed later confirmed mild osteoporosis.
    Despite having some set backs and not being able to implement all of the plan initially, the patient’s clinical course at the end of 5 months showed her with minor medial tibial pain, ongoing therapy with her counselor and support from her instructors, no binging and purging episodes but some continued caloric restriction. Her menses had returned but were irregular.

    Discussion
    Hopefully all children and adolescents live active lives, but activity may lead to injuries. Underconditioned or de-conditioned children are at increased risk of injury. In prepubertal children, the soft tissues are stronger than their muscular insertions or growth plates and therefore fractures are common. In skeletally mature adolescents, soft tissue injuries predominate.
    Trauma often can be found in the history but a health care provider also needs to remember that a healthy child or adolescent can also have other disease processes like any child can.
    For example, an ice skater could have hip pain from falling on the ice or Legg-Perthes disease.

    Learning Point
    Female athlete triad describes physically active girls and women who also have amenorrhea, osteoporosis, and disordered eating.

    Girls and women benefit from sports participation just as males do. With the increasing number of girls and women participating in sports, the triad is being more frequently recognized.
    Although anyone could have the triad, it is more common in sports involving endurance that emphasizes leaness (e.g. distance running, etc.), weight categories for participating (i.e. rowing, etc.), those emphasizing pre-pubertal body habitus (e.g. gymnastics, skating, etc.), those with body contour-revealing clothing (e.g. dance, weight lifting, swimming, etc.)

    The disordered eating may present with any variation including preoccupation with food, exercise or body image, caloric restriction, fasting, binging, purging or combinations. The problems are not limited to strict anorexia nervosa or buliminia nervosa patterns.
    The amenorrhea may range from oligomenorrhea to primary or secondary amenorrhea. Secondary amenorrhea occurs in 3-66% in female athletes compared to 2-5% of the general population.
    Osteoporosis is caused by impaired bone formation, premature bone resorption or both. During adolescence, a normal female gains more than 50% of her adult skeletal mass and 15% of her adult height. Peak bone mass is between 18-25 years with bone mass being lost at a rate of 0.3-0.5% annually. With oligomenorrhea, the adolescent is actually at risk of losing 2% of bone mass annually when she should be gaining bone mass.

    Treatment includes nutritional counseling for appropriate caloric ingestion. Adolescent athletes need extra calcium, protein and carbohydrates. Extra calcium (1500mg total/day) is recommended instead of the normal 1200 mg/day for non-athletes.
    Use of estrogen-progesterone combination medications may also be used to increase bone mineral density but this is recommended for skeletally mature athletes only.
    Increased nutrition and appropriate weight gain usually corrects the amenorrhea.

    Prevention includes education of athletes, parents, coaches, trainers etc. about proper nutrition, training practices and warning signs of the triad.
    Psychological pressure to conform to an ideal standard is counterproductive for an athlete to be in top performing condition.

    Questions for Further Discussion
    1. What are the indications for a bone mineral density scan?
    2. Can female athlete triad be also found in male athletes?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MEDLINEplus for these topics: Eating Disorders, Osteoporosis, Menstruation and Sports Fitness
    and at Pediatric Common Questions, Quick Answers for this topic: Compulsive Exercise and Eating Disorders.

    To view current news articles on this topic check Google News.

    Lerand SJ, Williams JF. The Female Athlete Triad. Pediatr Rev. 2006;27:e12-e13.

    Mier RJ, Brower TD. Pediatric Orthopedics, A Guide for the Primary Care Physician. Plenum Medical Book Co. New York. 1996;226.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa
    Dr. D’Alessandro would also like to thank Dr. George Phillips, Assistant Professor of Clinical Pediatrics for his assistance with this case.

    Date
    April 3, 2006