What is Causing These Spells?

Patient Presentation
A 35-day-old female referred to clinic for spells.
These began around 1 week of age occurring 1-2 times/day when the infant cried. The infant would become tachypneic for 2-3 seconds, have breath holding/apnea with no chest wall movement, then have blue lips hands and feet for another few seconds. The tachypnea then returns. There were no specific sounds made during the episodes The entire episode lasts less than 10 seconds.
The mother would stop these episodes by blowing in her face but denies shaking. Her eyes were open during these episodes without eye deviation, but arms and legs are stiff without any specific movements.
Overtime, the episodes are occurring 4-6 times per day for 10-20 seconds and were also occurring when the infant is asleep.
The infant is also head nodding in clusters which is not associated with any extremity movement or trunk position changes.
The past medical history shows a full-term infant born by vaginal delivery without complications. The infant was discharged home on time. She had regular care and was growing well.
The family history was non-contributory.
The review of systems is negative for any upper respiratory illness, eye changes, emesis, diarrhea. A day care provider has not had a recent pertussis vaccination.

The pertinent physical exam shows a well appearing female with normal vital signs. Weight was 4.6 kilogram (75%), head circumference was 38 centimeters (90%) with 99% saturation on room air.
HEENT shows no obvious dysmorphic features with an open anterior fontanelle and very mild left positional plagiocephaly.
Neuro exam revealed the general impression of increased jitteriness with handling and 6 beats of clonus bilaterally in the feet.
The rest of the examination was negative.
No episodes were seen in clinic.
The diagnosis was unclear but possible infantile spasms or other seizure, cardiac or metabolic abnormality were considered highly likely.
Sepsis was also considered but these spells been present for a while and was considered less likely. Gastroesophageal reflux was also considered but felt to be less critically important to evaluate than the other possibilities.
The infant was admitted to the hospital where during her clinical course she had evaluations for possible seizure (neurology consultation, video EEG, and brain MRI that were all negative), cardiac abnormalities (chest radiograph, 4 point blood pressures, and electrocardiogram were negative) and metabolic abnormalities (complete blood count, glucose, chemistries, calcium, phosphorus and magnesium were negative.).
As these evaluations were occurring, several episodes were seen by health care providers and were described as having respiratory difficulties that then caused the infant to cry and change posture including head nodding. No actual apnea was noted, but the infant did have severe respiratory distress during the episodes. The episodes resolved spontaneously within 10 seconds.
Otolaryngology was consulted and an endoscopy revealed the diagnosis of severe laryngomalacia type 1 and 2 was made. The patient was monitored and had 3 self-resolving episodes within 24 hours. She was discharged with an apnea monitor and followup with otolaryngology in 1 week.

Discussion
Spells, episodic or paroxysmal events can be very difficult to evaluate. They seem to occur randomly, often inconsistently, and are described by independent observers differently.
These descriptions also make it difficult to tell if the problem falls into one area versus another, such as a seizure versus apnea.
Not surprisingly the clinical signs and symptoms and the differential diagnoses of these events markedly overlap.
Many times it is necessary to start evaluating a patient for a potentially more life-threatening problem or several problems at once, while at the concurrently, gathering new information and re-evaluating the possible diagnoses.
Compounding this difficulty are the evaluation methods themselves, as many tests are invasive (ie bronchoscopy), expensive (ie computed tomography or magnetic resonance imagine) and can be imprecise (i.e. electroencephalogram).
Additionally, parents want answers and health care providers are dealing with the ambiguity. Many times an answer is found and treatment can be instituted, but sometimes with these events remain unsolved.

Learning Point

The differential diagnosis of episodic events includes:

  • Seizure
    • Epilepsy
    • Febrile seizure
    • Psychogenic seizure
    • General problems affecting the brain
      • Drugs/toxins

      • Fever
      • Hypertension
      • Hypoxia
      • Metabolic abnormalities
    • Specific problems affecting the brain
      • Stroke

      • Trauma
      • Tumor
  • Apnea and respiratory distress
  • Inattention, daydreaming
  • Gastroesophageal reflux disease
  • Migraine
  • Myoclonus
  • Narcolepsy
  • Night terrors, nightmares
  • Paroxysmal diakinesia
  • Rages
  • Shuddering
  • Syncope
  • Tics
  • Vertigo

The differential diagnosis of respiratory distress can be found here.

The differential diagnosis of apnea includes:

  • Central nervous system depression
    • Apparent life-threatening event/SIDS

    • Cerebral edema
    • Cerebral hemorrhage
    • Cerebral hypoxia
    • Congenital malformation
    • Drugs/toxins
    • Metabolic abnormalities
    • Meningoencephalitis
    • Prematurity including apnea and bradycardia
    • Tumor
  • Airway abnormalities
    • Bronchopulmonary dysplasia

    • Tracheolaryngomalacia
    • Tracheoesophageal fistula
    • Choanal stenosis or atresia
    • Obstructive sleep apnea
  • Asthma
  • Aspiration
    • Gastroesophageal reflux disease

    • Foreign body
  • Botulism
  • Cardiac arrhythmias
  • Congenital heart disease
  • Congestive heart failure
  • Child maltreatment
  • Guillian Barre syndrome
  • Infectious
    • Bronchiolitis

    • Croup
    • Epiglottis
    • Influenza
    • Necrotizing enterocolitis
    • Sepsis and bacteremia
    • Pertussis
    • Pneumonia
  • Metabolic abnormalities
    • Hyperammonemia

    • Hypoglycemia
    • Hypocalcemia
    • Hypernatremia
  • Primary alveolar hypoventilation
  • Seizures
  • Trauma
    • Head trauma

    • Hypothermia
    • Smoke inhalation

Questions for Further Discussion
1. With this patient, what was on your original differential diagnosis and how would you have managed this patient differently?
2. What is West Syndrome?
3. What are the different types of laryngomalacia?

Related Cases

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

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tracheal Disorders

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

To view images related to this topic check Google Images.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:139-140.

Berkowitz C. Pediatrics A Primary Care Approach. WB Saunders Co. Philadelphia, PA. 1996:103,135.

Kotagal P, Costa M, Wyllie E, Wolgamuth B. Paroxysmal nonepileptic events in children and adolescents. Pediatrics. 2002 Oct;110(4):e46.

Tschudy MM, Arcara KM. The Harriet Lane Handbook. 19th. Edit. Elsevier/Mosby Publications: Philadelphia, PA. 2012:466, 511, 513.

Rocker JA. Pediatric Apnea. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/800032-overview (rev. 5/7/2012, cited 9/18/12).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.
    7. All medical and invasive procedures considered essential for the area of practice are competently 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.

    Author

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

  • What Are the Causes of Premature Atrial Contractions?

    Patient Presentation
    A 6-year-old male came to clinic for a pre-operative surgical evaluation. The boy had attention deficit hyperactivity disorder with marked inattention and some behavioral issues. He had recently been tried on methylphenidate but was currently off the medication because of side effects and had a return appointment with his psychiatrist. He was otherwise well, except for dental caries necessitating oral rehabilitation under general anesthesia. The past medical history showed surgery for pressure equalizing tubes without any problems. The family history was positive for a cousin who had died from an unknown cardiac problem. The review of systems was negative including no palpitations, dyspnea or syncope.

    The pertinent physical exam showed heart rate of 96, and a normal blood pressure without a widened pulse pressure between the upper extremities and lower extremities. HEENT revealed rampant caries and scarred tympanic membranes bilaterally. Heart examination found a grade I/IV systolic murmur best at the mid-left sternal border without radiation that changed with position and respiration. There were no bruits or jugulovenous distention and he had normal femoral pulses. He had an irregularly irregular heart beat with each beat pulsating to the extremities. The rest of his examination was normal.

    The work-up included a normal chest radiograph and a 12-lead electrocardiogram with a long rhythm strip. The general pediatrician’s reading of the ECG showed normal consistent P and QRS wave morphologies. There was a P wave for every QRS and a QRS for every P wave. There were several premature beats on the rhythm strip that appeared randomly. There did not appear to be any left ventricular hypertrophy. The pediatrician thought this was premature atrial contractions but she did not read many ECGs, and felt that there were frequent premature beats, and because the patient had a concerning family history and possible need for stimulant medication in the future for his attention issues, she contacted a cardiologist. The ECG and rhythm strip were sent to a pediatric cardiologist who confirmed the diagnosis of premature atrial contractions. He felt that the child could undergo surgery without further immediate evaluation, but because of the same concerns the general pediatrician had that a cardiology appointment and Holter monitor would be appropriate in the near future and before stimulant medication was started.

    Case Image
    Figure 100 – ECG demonstrating premature atrial contractions

    Discussion
    A cardiac arrhythmia or dysrhythmia is an abnormality in the cardiac muscle contraction or variation in the normal rhythm. This includes rhythm loss, irregular rhythms or abnormal regular rhythms. Arrhythmias can present in a number of ways including as an incidental finding, palpitations, syncope, sudden cardiac death or near death. The current recommendations by the American Academy of Pediatrics does not recommend routine a ECG before initiating stimulant medication for Attention Deficit Hyperactivity Disorder, but does recommend a targeted family history and physical examination. If there are any concerns, then further evaluation should be obtained before starting medication. Likewise, if stimulant medication is started the history or examination changes then again further evaluation is warranted.

    Premature atrial contractions (PACs) are common in neonates and children. The ECG findings show a normal to narrow QRS complex with an incomplete compensatory pause. That means that the total length of two cycles that includes a premature beat is less than 2 regular cycles. Sometimes a PAC is not followed by a QRS complex because the QRS is not conducted. The P waves may have different morphology depending where they are located in the atria; it is upright when the focus is high in the atria and can be inverted when low in the atria.

    How frequent is too frequent is hard to discern but one study of adults states that having PACS 100 times/day is frequent. When PACs are frequent, a more extended evaluation is often done (i.e. a Holter or event monitor and echocardiogram) to rule out an underlying structural abnormality or arrthymogenic cause. Frequent PACs in children do not appear to have any hemodynamic consequences, but there are studies in older adults where PACs appear to predict new occurrences of atrial fibrillation and its associated cardiovascular events.

    Learning Point
    The causes of PACs includes digitalis toxicity, caffeine, theophylline or other stimulant, post-cardiac surgery and during pregnancy. PACs usually cause no hemodynamic problems and generally no treatment is necessary in children. Treatment is for an underlying cause if one is discovered. PACs associated with gestation usually resolve with delivery.

    Questions for Further Discussion
    1. What other arrhythmias originate in the atria?
    2. What are indications for a cardiology evaluation?
    3. What are relative contraindications to pre-scheduled general anesthesia?

    Related Cases

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Arrhythmia

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

    To view images related to this topic check Google Images.

    Perrin JM, Friedman RA, Knilans TK; Black Box Working Group; Section on Cardiology and Cardiac Surgery. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics. 2008 Aug;122(2):451-3.

    Tanel RE. ECGs in the ED. Pediatr Emerg Care. 2011 Dec;27(12):1203-4.

    Chong BH, Pong V, Lam KF, Liu S, Zuo ML, Lau YF, et al. Frequent premature atrial complexes predict new occurrence of atrial fibrillation and adverse cardiovascular events. Europace 2012;14:942-7.

    Tschudy MM, Arcara KM. The Harriet Lane Handbook. 19th. Edit. Elsevier/Mosby Publications: Philadelphia, PA. 2012:174-76.

    Pickett C, Zimmerman PJ. Evaluation of Palpitations. ePocrates. Available from the Internet at https://online.epocrates.com/u/2912572/Evaluation+of+palpitations/Differential/Etiology (rev. 5/24/2012, cited 9/17/2012).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.
    7. All medical and invasive procedures considered essential for the area of practice are competently 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
    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
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

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

  • What are the Initial Cerebrospinal Fluid Findings in Different Types of Meningitis?

    Patient Presentation
    An 8-year-old male came to the emergency room with 3 days of fever, malaise and an increasing headache. His fever had a maximum temperature of 102.4° F. He had been increasingly tired and sleeping more. He was seen on day 2 and was diagnosed with an early upper respiratory infection. Over the next 24 hours, he became more irritated when awake. He was drinking and urinating little and had developed a generalized headache. He also complained of back pain with moving. The past medical history was non-contributory. The review of systems showed no emesis, constipation, or diarrhea. He may have had a rash on his trunk at the beginning of the illness.

    The pertinent physical exam showed an ill-appearing child, who was in a fetal position and did not want to be moved, but was cooperative. His vital signs were normal. His capillary refill was 3 seconds. Eye examination found photophobia which made it difficult to appropriately examine the retinas. He had mild erythema of the posterior pharynx and showed some nucal rigidity. He complained of pain in his lower back with straight leg lift, but no change with straightening his knee. He complained of generalized pain with most movement. His neurological examination showed cranial nerves were intact, DTRs were 2+/2+ with normal strength. His skin showed a faint, blanching, macular diffuse rash on his abdomen.

    The radiologic evaluation included head computed tomography that was negative for a space occupying lesion. The laboratory evaluation had a complete blood count remarkable for being 19.6 x 1000/mm2 with an increased lymphocytic count and normal platelets. Electrolytes, glucose, and urinalysis were normal. Liver function tests showed a mild increase in transaminases. The work-up included a lumbar puncture as soon as the head computed tomography was completed. Opening pressure was 74 mm H20 (normal 60-200 mm). It showed 19 lymphocytes, glucose of 28 mg/dL, and protein of 33 mg/dL, with no organisms on gram stain. Cerebrospinal fluid for culture and polymerase chain reaction (PCR) were sent. Blood and urine cultures were sent. The diagnosis of meningitis was made. He was given intravenous ceftriaxone, acyclovir and fluids, and transported to a regional children’s hospital for admission and treatment. The patient’s clinical course found the PCR was positive on day 2 for Echovirus 9 and antibiotics and acyclovir were discontinued. He slowly improved with lessening headache and malaise. On day 3 he had adequate fluid intake and was discharged home.

    Discussion
    Meningitis is an inflammation of the meninges. While any organism or disease process can cause severe neurological sequelae or death, most feared usually are rapidly growing bacteria such as meningococcus. Aseptic meningitis is usually caused by nonbacterial organisms and other diseases including enteroviruses, measles, mumps, and mycoplasma. About 75,000 cases occur in the US each year. Organisms colonize the person usually in the nasopharyngeal mucosa, spread to the blood steam and eventually reach the meninges by the blood-brain barrier and cerebrospinal fluid after evading the person’s immunological defenses.

    Meningitis classically has symptoms of headache, photophobia and nucal rigidity, but these may be subtle or absent especially in younger children. Nucal rigidity is notoriously inconsistent in children less than 2 years and therefore decisions about evaluation and treatment must be presumptively made based on overall presentation and history. Fever and rash can also be seen. Diarrhea or cough may be present.

    Laboratory testing usually includes complete blood count, C-reactive protein, cultures (blood, urine, CSF and possibly stool, throat), and CSF studies including PCR for enteroviruses. Blood serology (acute and convalescent) may also be important.

    Presumptive treatment depends on the age and other risk factors. A broad spectrum third generation cephalosporin is usually started along with possible additional coverage for Listeria in neonates and for herpes simplex.

    Complications of meningitis include disseminated intravascular coagulation, septic shock, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, increased intracranial pressure, obstructive hydrocephalus (especially with tuberculous meningitis), subdural effusion, hearing loss, and abscess formation. Each of these has its own set of potential resulting complications too.

    Learning Point
    Patients should be stable to undergo a lumbar puncture procedure. If not, the patient must be stablized, treated presumptively and when well enough, have the procedure. Other contraindications to lumbar puncture includes hemophilia or severe thrombocytopenia, a space occupying lesion or infection near or over the lumbar puncture site.

    Although appropriate cultures and PCR are the gold-standard, laboratory testing does provide important information for initial diagnosis, management and treatment of suspected meningitis. Laboratory testing aids in distinguishing between major etiological groupings. It is not uncommon that patients with aseptic meningitis are treated for presumed bacterial meningitis and/or herpes meningitis until confirmatory testing is available. It is also common that patients are presumptively treated before CSF studies are obtained because of the acuity of their presenting symptoms. Tuberculosis and fungal meningitis are less common in the U.S., however they should still be considered in at risk populations or patients with complicated clinical courses. In these cases, extra tubes of CSF that are banked can then be tested.

    Initial cerebrospinal fluid findings in different types of meningitis includes:

    Bacterial Partially
    Treated
    Viral Tuberculosis Fungal
    WBC Count > 500 200-500 10-100 50-500 25-500
    WBC Type Mostly neutrophils Lymphocytes Early neutrophils,
    Late Lymphocytes
    Lymphocytes Lymphotyes
    Glucose (mg/dL) < 40 < 40 > 40 < 40 < 40
    Protein (mg/dL) 100 < 40 < 100 50-500 25-500
    Gram Stain Positive Negative Negative Rarely acid fast
    bacillus positive
    May be positive
    with special stain
    Culture Positive Positive Negative Negative Negative

    Questions for Further Discussion
    1. What are indications for admission to the intensive care setting with posible meningitis?
    2. What prophylactic treatment should be offered to close contacts of meningitis patients?
    3. What criteria constitutes a close contact?

    Related Cases

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Meningitis

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

    To view images related to this topic check Google Images.

    Leih-Lai, M. Asi-Bautista MC, Ling-McGeorge K. The Pediatric Acute Care Handbook. Little Brown and Co., Boston, MA 1995;88-93..

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:900-904.

    Faust, SN. Pediatric Aseptic Meningitis. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/972179-overview (rev. 8/3/12, cited 8/20/12).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.
    7. All medical and invasive procedures considered essential for the area of practice are competently 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.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

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

  • How Fast Do Fingernails Grow?

    Patient Presentation
    A 4-year-old female came to clinic for her health maintenance examination. Her mother noted that she bit her fingernails. During the conversation, the mother asked how fast fingernails grow. The intern physician said he didn’t know but would ask. The attending physician said that he wasn’t sure but that it was a few millimeters per month generally, and that illness and other stresses could decrease the rate and pregnancy could increase the rate. The diagnosis of onchophagia was made. The mother was given this answer along with some ideas on how to try to decrease the nail biting.

    Discussion
    Onchophagia or nail biting is a common disorder in children and adults. It is often due to habit but can become so prevalent that it is compulsive in some individuals. Understanding the situations when the behavior is more common (i.e. stressful situations, when bored, etc.) and finding ways to decrease the triggering situation is helpful. Additionally, finding ways to compete with the behavior is also helpful (i.e. holding on to clothing, sitting on the hands). Another alternative is to use deterrents such as nail polish that has a bad taste or using gloves to cover the hands.

    Habit reversal training can also be helpful to decrease the behavior, and more information can be found here.

    Learning Point
    Fingernail growth is important as nails have been used for biomarking in epidemiological studies for toxins, drugs and nutrients over the past 20-30 years. Data on growth is unfortunately limited, and many studies are from more than 30 years ago.

    In 2009, one study of young adults found that fingernail growth was faster than of toenails with great toes and thumbs having the highest rates on each extremity. Hand or foot dominance was not significant. Onchophagia was associated with faster nail growth but was not statistically significant. The average fingernail growth rate was 3.47 mm/month and toenail growth was 1.62 mm/month.

    In a 1959 study, fingernail growth in adults was found to be 1.9-4.4 mm/month, with normal infants averaging 3.36 mm/month and premature infants (weight 1150-1900g) having a rate of 2.55 mm/month. The researchers also demonstrated growth arrest in a variety of acute and chronic diseases including measles and nutritional deficiencies. Interestingly, they also documented post-mortem nail growth in 3 adults followed for 8-10 days after death. They found a slightly decreased but normal fingernail growth rate for the first 2-3 days after death, and then a slower rate during the rest of the study period. The growth had not stopped at the time of discontinuation of the observations.

    Questions for Further Discussion
    1. How fast does hair grow?
    2. At what age can you tell the permanent color of eyes?
    3. Nails can be tested for what substances?

    Related Cases

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Nail Diseases.

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

    To view images related to this topic check Google Images.

    Sibinga MS. Observations on growth of fingernails in health and disease. Pediatrics. 1959 Aug;24(2):225-33.

    Yaemsiri S, Hou N, Slining MM, He K. Growth rate of human fingernails and toenails in healthy American young adults. J Eur Acad Dermatol Venereol. 2010 Apr;24(4):420-3.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.

  • 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
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

    Author

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