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Answer: D Explanation: Ototoxicity and red man syndrome are associated with vancomycin antifungal vagisil buy ketoconazole 200 mg online. Myalgias and rhabdomyolysis have been reported with daptomycin therapy and require patient education and monitoring quantum anti-fungal formula purchase 200mg ketoconazole mastercard. Which one of the following is the most common side effect of antihyperlipidemic drug therapyfi Answer: B Explanation: Gastrointestinal disturbances frequently occur as a side effect of antihyperlipidemic drug therapy antifungal group generic ketoconazole 200mg with amex. Case of old patient with signs and symptoms of Parkinson Disease antifungal imidazole cheap ketoconazole 200mg, where is the lesionfi Answer: basal ganglia fungus link diet buy ketoconazole 200mg low cost, and there will be decreased basal ganglia pre-synaptic dopamine uptake fungus normal plague inc order discount ketoconazole on line. Explanation: Propylthiouracil is one of the drugs used to treat hyperthyroidism (thyrotoxicosis) by Inhibiting thyroid hormone synthesis. Supraphysiologic dose of Corticosteroids are the 1st treatment line (prednisolone 12. It is one of the commonest gynaecological conditions that affects the quality of life of many women in their reproductive years. Primary dysmenorrhoea occurs in the absence of pelvic pathology Secondary dysmenorrhoea occurs in the presence of pelvic pathology such as: Pelvic inflammatory disease, Endometriosis, Adenomyosis, Uterine leiomyoma and Uterine polyps. Primary dysmenorrhea occurs 6 to 12 months following menarche and at the same time clinical investigations fail to reveal an underlying pelvic pathology, where By contrast, secondary dysmenorrhoea often occurs years after the onset of menarche when the woman is in her 30s or 40s. Treatment options for Primary dysmenorrhea: fi Patient education and reassurance fi Nonpharmacologic interventions such as application of a heat pack to the lower abdomen, exercise, and relaxation techniques. For women with primary dysmenorrhea desiring contraception, estrogen-progestin contraceptives are a logical choice. Treatment of Acute myeloid (myelogenous) leukaemia: Answer: Induction chemotherapy using cytarabine plus an anthracycline. Explanation: the backbone of treatment is chemotherapy, specifically, cytarabine plus an anthracycline. High doses of nitrates can also cause postural hypotension, facial flushing, and tachycardia. A 62-year-old patient with a history of asthma and vasospastic angina states that he gets chest pain both with exertion and at rest, about ten times per week. One sublingual nitroglycerin tablet always relieves his symptoms, but this medication gives him an awful headache every time he takes it. Answer: B Explanation: Calcium channel blockers are preferred for vasospastic angina. The nitroglycerin spray would also be expected to cause headache, so this is not the best choice. Ranolazine is not indicated for immediate relief of an angina attack, nor is it a firstline option. Which medication should be prescribed to all angina patients to treat an acute attackfi It also finds use prophylactically in reducing breast cancer occurrence in women who are at high risk. Tamoxifen is currently used in the treatment of metastatic breast cancer, or as adjuvant therapy following mastectomy or radiation for breast cancer. Both tamoxifen and raloxifene (selective estrogen receptor modulator) can be used as prophylactic therapy to reduce the risk of breast cancer in high-risk patients. Raloxifene is also approved for the prevention and treatment of osteoporosis in postmenopausal women. Side effects caused by tamoxifen include hot flashes, nausea, vomiting, skin rash, and vaginal bleeding and discharge (due to estrogenic activity of the drug and some of its metabolites). Hot flashes and leg cramps are also common adverse effects with raloxifene (selective estrogen receptor modulator). Unlike estrogen and tamoxifen, raloxifene does not result in an increased incidence of endometrial cancer. Which of the following antianginal medications would be of particular concern in this patientfi Answer: Fibrates or Niacin (Fibrates is the better answer if both were there in the exam) Explanation: Diet and exercise are the primary modes of treating hypertriglyceridemia. If indicated, niacin and fibric acid (Fibrates) derivatives are the most efficacious in lowering triglycerides. Fibrates: the fibrates such as: gemfibrozil and, fenofibtic acid are used in the treatment of hypertriglyceridemias. Which one of the following drugs causes a decrease in liver triglyceride synthesis by limiting available free fatty acids needed as building blocks for this pathwayfi The liver normally utilizes these circulating fatty acids as a major precursor for triglyceride synthesis. Pt with acetaminophen overdose sinc 24 min,conscious and cooperative, the best initial managementfi The main goal of treatment is to prevent or minimize liver injury following paracetamol overdose. Charcoal should be withheld in patients who are sedated and may not be able to protect their airway, unless endotracheal intubation is performed first. This is accomplished by initiating treatment within eight hours of an acute ingestion. The best available data suggest that both routes are effective and differences are minimal. A 27-year-old female presents to the emergency department 6 hours after reportedly ingesting 20 tablets of acetaminophen 500 mg. An acetaminophen level is drawn, but it has to be sent out to another lab and will not return for another 6 hours. The optimal time frame to give N-acetylcysteine is within 8 to 10 hours postingestion. So, waiting on the level to return would put the patient more than 12 hours postingestion. Reference: UpToDate, available at: press "Ctrl" and click here to download or link. Case about a diabetic who takes metformin which resulted in correction of Hba1c, Metformin lowers glucose byfi Explanation: the main mechanism of action of metformin is reduction of hepatic gluconeogenesis. Metformin also slows intestinal absorption of sugars and improves peripheral glucose uptake and utilization. Patient presented with typical symptoms of angina relieved by using sublingual drug what is the mechanism of action of this drugfi Answer: Most likely they gave him nitrates Most likely the mechanism of action is the dilation of the large veins and reducing preload Explanation: Organic nitrates relax vascular smooth muscle In additions Nitrates such as nitroglycerin cause dilation of the large veins, which reduces preload (venous return to the heart) and, therefore, reduces the work of the heart. Nitrates also dilate the coronary vasculature, providing an increased blood supply to the heart muscle. Answer: Buprenorphine and Methadone both are correct, choose Buprenorphine if both were in the choices Explanation: Buprenorphine has a major use is in opioid detoxification, because it has shorter and less severe withdrawal symptoms compared to methadone. Methadone is also used in the controlled withdrawal of dependent abusers from opioids and heroin. Oral methadone is administered as a substitute for the opioid of abuse, and the patient is then slowly weaned from methadone. Boy with hypopigmented lesion in the back and extremities becomes lighter (shine) with sun exposure, Treatment A. They are visible primarily in contrast to dark skin; increasing sunlight in spring and summer also makes them more apparent. Treatment: Conservative: Pityriasis alba resolves spontaneously with trigger avoidance, good general skin care, and education. Reference: Uptodate, available at: press "Ctrl" and click here to download & Toronto notes 2017, Page Neurology N43 39. Steroids Answer: B Steroids like dexamethasone Explanation: Croup (laryngotracheitis) is a respiratory illness characterized by inspiratory stridor, barking cough, and hoarseness. It typically occurs in children six months to three years of age and most commonly is caused by parainfluenza virus. Children with moderate to severe croup should also receive supportive care including humidified air or oxygen, antipyretics, and encouragement of fluid intake. Patient on nebulized steroid, developed white patches on tongue (mouth), what is the diagnosisfi Answer: most likely the diagnosis is Oral candidiasis or oral thrush Explanation: Immunosuppressive agents. Answer: B Explanation: Spironolactone is added only for resistant hypertension with failed combined regime Or with heart failure patients. In this scenario, the patient is controlled, and we may try stopping spironolactone because of the high risk for electrolyte disturbances. Reference: uptodate available at: press "Ctrl" and click here to download Or bestpractice. Reference: uptodate available at: press "Ctrl" and click here to download Or. Answer: most likely digoxin-specific antibody (Fab) fragments Explanation: Arrhythmia is the most dangerous manifestation of digitalis (cardiac glycoside) poisoning. We recommend that any patient with clinically significant manifestations of digitalis poisoning. We suggest not treating hyperkalemia in patients with digitalis poisoning with anything other than Fab fragments; due to risk of hypokalemia. Patients suspected of having acute digitalis intoxication who present to the emergency department within one to two hours of ingestion may benefit from the administration of activated charcoal. Answer: if the patient is having severe symptoms like agitation and delusion you may give Atypical antipsychotics first Like: olanzapine or risperidone. Explanation: Antipsychotic agents have limited efficacy and are associated with increased mortality in patients with dementia. However, their benefits often still outweigh their risks in patients with dementia when treatment of hallucinations and delusions is critical to patient and caregiver safety and well-being. Answer: methimazole or propylthiouracil (choose methimazole if multiple options are present within the question) Explanation: Complications of Antithyroid drugs (also called thionamides therapy), including agranulocytosis and hepatotoxicity, Agranulocytosis is a rare but serious complication of thionamide therapy Both methimazole and propylthiouracil were associated with Agranulocytosis. Reference: uptodate available at: press "Ctrl" and click here to download Or Lippincott illustrated review of pharmacology 6th ed, page 332 51. Physiotherapy Answer: most likely diagnosis is osteoarthritis which its 1st management is local anesthesia + physiotherapy, but the cornerstone therapy is none pharmalogical which include physiotherapy. Glyburide Answer: C Explanation: Major adverse effects of the sulfonylureas are weight gain, hyperinsulinemia, and hypoglycemia. Incretin hormones are responsible for 60% to 70% of postprandial insulin secretion. Acarbose Answer: most likely basal insulin should be started; due to his sulfa allergy (None of the choices above). Olanzapine Answer: B Explanation: Weight gain and metabolic effects are the most prominent side effects of Second-generation antipsychotic medications. Clozapine and olanzapine are especially associated with these problems, whereas aripiprazole, lurasidone, and ziprasidone are the preferred agents to minimize these issues. Patient with renal stones was given a diuretic to lower the ca then he developed Gout, what medication was used: A. Furosemide Answer: B Explanation: Hyperuricemia is a relatively common finding in patients treated with a loop or thiazide diuretic and may, over a period of time, lead to gouty arthritis. But experts now recommend that propylthiouracil be given during the first trimester only. This is because there have been rare cases of liver damage in people taking propylthiouracil. After the first trimester, women should switch to methimazole for the rest of the pregnancy. Medications which contain amphetamine such as Benzedrine, Dexedrine, and Ritalin Dexamethasone, and prednisone. Phenytoin, Levodopa, Medicines that contain caffeine, such as Anacin, Empirin, Excedrin, No-Doz, and cough medicines Decongestants, such as phenylephrine Illegal drugs, such as cocaine Quinidine. Like all bisphosphonates, it is chemically related to inorganic pyrophosphate, the endogenous regulator of bone turnover.

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Some patients with hypocalcemia exhibit bizarre behavior fungus parasite order 200 mg ketoconazole amex, irritability antifungal ear drops buy ketoconazole 200 mg online, loss of consciousness antifungal topical trusted ketoconazole 200 mg, and conof serum level and urinary calcium excretion fungus between breasts generic 200mg ketoconazole overnight delivery. Headache fungus that looks like carrot ketoconazole 200 mg overnight delivery, vomiting antifungal cream for toenails generic ketoconazole 200 mg amex, increased intracranial prestal calcium can often be discontinued in patients with rickets after vitamin D therapy has stabilized. Selection are reduced in many hypocalcemic conditions, but may be and dosage of vitamin D supplements varies with the underelevated in pseudohypoparathyroidism or severe vitamin D lying condition and the response to therapy. Measurement of urinary excretion of calcium as therapy is essential to avoid toxicity. Imaging month intervals is necessary to ensure adequate therapy and Soft tissue and basal ganglia calcification may occur in to prevent hypercalcemia and nephrocalcinosis. Various skeletal changes are associated with rickets, nance of serum calcium and phosphorus concentrations including cupped and irregular long bone metaphyses. Torwithin normal ranges, (2) normalization of alkaline phossional deformities can result in genu varum (bowleg). Accenphatase activity for age, (3) regression of skeletal changes, tuation of the costochondral junction gives the rachitic and (4) maintenance of an age-appropriate urine calciumrosary appearance seen on the chest wall. Chronic renal disease with eratively and is continued until serum calcium concentrations impaired phosphate excretion is the most common secondare normal and stable. Long-term therapy for hypercalcemia of malignancy is the treatment of the underlying disorder. The prognosis following subtotal parathyroidectomy behavior; nausea, vomiting, abdominal pain, constipation, for diffuse hyperplasia or removal of multiple adenomas is and weight loss; hyperextensibility of joints; and hypertenusually good and depends on correction of the underlying sion, cardiac irregularities, bradycardia, and shortening of the defect. Familial hypocalciuric hypercalcemia is distinguished by low to normal urinary calcium excretion as a result of high renal 3. There is a there is generalized demineralization with high risk of sublow rate of new mutations. A severe form of symptomatic neonatal hyperparathyroidism may occur in infants homoB. Vitamin D intoxication is almost always the result of ingestion of excessive amounts of vitamin D. Severe hypercalcemia Initial management is vigorous hydration with normal saline requires hospitalization and aggressive intervention. Due to and forced calcium diuresis with a loop diuretic such as the storage of vitamin D in the adipose tissue, several months furosemide (1 mg/kg given every 6 hours). Chronic Hypercalcemia characterized by elfin-appearing facies and hypercalcemia in Treatment options vary with the underlying cause. Abrupt immobilization, particularly in a rapidly growing adolescent, may cause hypercalcemia and hypercalciuria. Hypophosphatasia is a rare autosomal recessive condition When an infant is born with ambiguity, immediate consultacharacterized by deficiency of alkaline phosphatase activity in tion with pediatric endocrinology, urology, and if possible serum, bone, and tissues. Disorders of sexual differentiation skeletal mineralization with clinical and radiographic features stem from alterations in three main processes: gonadal similar to rickets. Disorders of Gonadal Differentiation failure to thrive, hypotonia, and craniosynostosis. They have phoethanolamine associated with low serum alkaline phosphacompletely normal female external genitalia and present as tase. Calcicharacterized by masculine or ambiguous genital developtonin may be of value for the acute treatment of hypercalcemia. In Lifshitz must have both ovarian and testicular tissue and typically has F (editor): Pediatric Endocrinology, 5th ed. DysgeZajickova K et al: Identification and functional characterization of netic gonads have an increased risk for neoplastic transfora novel mutation in the calcium-sensing receptor gene in mation. Because of decreased testosterone production in familial hypocalciuric hypercalcemia. The genital ridge contains gonadal tissue, and and produces antimullerian hormone. Thus, females with congenital adrenal hyperplasia who are virilized as the result of circulating androgens do not have wolffian duct development. Normal male development is also dependent on regression of mullerian duct derivatives through the local action of mullerian inhibiting factor elaborated by the Sertoli cells of the adjacent testis. Elevated concentrations of other (adrenal) androgens, as occurs in females with congenital adrenal hyperplasia, can virilize the genital tubercle, and cause genital swelling and genital/urethral folds, resulting in varying degrees of ambiguity. Maternal plete, the external genitalia may masculinize at puberty when exposure to androgens or androgen antagonists is a rare testosterone production increases. Disorders of Androgen Action Precocious puberty is defined as pubertal development occurDefects in testosterone action result from absent or defective ring below the age limit set for normal onset of puberty. Depending on Puberty is considered precocious in girls if the onset of secondthe degree of abnormality in androgen binding, the genital ary sexual characteristics occurs before age 8 years. Precocious phenotype can range from relatively mild male ambiguity to puberty is more common in girls than in boys. The age tracheoesophageal fistula with esophageal atresia, and radial of pubertal onset may be advanced by obesity. The pathways illustrated are present in differing amounts in the steroid-producing tissues: adrenal glands, ovaries, and testes. In the adrenal glands, mineralocorticoids from the zona glomerulosa, glucocorticoids from the zona fasciculata, and androgens (and estrogens) from the zona reticularis are produced. The major adrenal androgen is androstenedione, because the activity of 17-ketoreductase is relatively low. The pathways leading to the synthesis of mineralocorticoids and glucocorticoids are not present to any significant degree in the gonads; however, the testes and ovaries each produce both androgens and estrogens. Further metabolism of testosterone to dihydrotestosterone occurs in target tissues of the action of the enzyme 5fi-reductase. Central nervous system abnormalities physical events in central precocious puberty is identical to a. Familial male-limited gonadotropin independent precocious pendent) occurs independent of gonadotropin secretion. With treatment, physical changes of this mutation have autonomous hyperfunction and secrete puberty regress or cease to progress, and linear growth slows excess amounts of their respective hormones. Projected final heights often increase as a result of slowing of skeletal maturation. After stopping therapy, pubertal progression resumes, and ovulation and pregnancy have Female central precocious puberty usually starts with breast been documented. Therapy is instituted for both psychosodevelopment, followed by pubic hair growth and menarche. Girls with ovarian cysts or tumors Treatment of peripheral precocious puberty is dependent generally have signs of estrogen excess such as breast develon the underlying cause. Adrenal tumors or intervention is generally not necessary, as the cyst usually congenital adrenal hyperplasia produce signs of adrenarche regresses spontaneously. Treatment with glucocorticoids is (ie, pubic hair, axillary hair, acne, and sometimes, increased indicated for congenital adrenal hyperplasia. Children with precocious puberty usually have tion is indicated for the rare adrenal or ovarian tumor. In McCune-Albright syndrome, therapy with antiestroHowever, because skeletal maturation advances at a more gens (eg, tamoxifen), agents that block estrogen synthesis rapid rate than linear growth, final adult stature may be (ketoconazole), or aromatase inhibitors (eg, letrozole) may compromised. Regardless of the cause of precocious puberty or the medical therapy selected, attention to the psychological B. One of the first steps in evaluating a child with early pubertal development is obtaining a radiograph of the left hand and 2. Benign Variants of Precocious Puberty wrist to determine skeletal maturity (bone age). If the bone Premature thelarche (benign early breast development) age is advanced, further evaluation is warranted. Onset of thelarche after age 36 months or in inhibition of the hypothalamic-pituitary axis by the autonoassociation with other signs of puberty requires evaluation. In girls Premature adrenarche (benign early adrenal maturation) with an ovarian cyst or tumor, estradiol levels will be markis manifested by development of pubic hair and body odor, edly elevated. In girls with signs of adrenarche and an and less commonly, axillary hair and can occur before age 8 advanced bone age, androgen levels (testosterone, androyears. No increase in growth rate or skeletal maturation stenedione, dehydroepiandrosterone) and possible adrenal occurs, and no abnormal virilization (eg, clitoromegaly) is intermediate metabolites (such as 17-hydroxyprogesterone) present. In either primary or central hypogonadism, signs of adrenarche are Delayed puberty in girls should be evaluated if there are no generally present. Delayed menarche or secondary amenorrhea may result Failure to complete pubertal development to Tanner stage V from primary ovarian failure or central hypogonadism, or within 4 years of onset is considered delay. Primary amenormay be the consequence of hyperandrogenism, anatomic rhea refers to the absence of menarche, and secondary obstruction precluding menstrual outflow, or mullerian amenorrhea refers to the cessation of established menses for agenesis. The timing of puberty is related to the bone age, not amenorrhea, breast development, and absence of sexual hair. Primary hypogonadism in girls refers to a primary abnorExternal genitalia are female because of the lack of androgen mality of the ovaries. At puberty, testosterone produced in the testes is category is Turner syndrome, in which the lack of or an aromatized to estrogen resulting in breast development. Radiation and commenced, level of exercise, nutritional intake, stressors, chemotherapy can also cause primary ovarian insufficiency. Central assessed to determine if height and weight velocity have been hypogonadism can be functional (reversible), or caused by appropriate. Physical examination includes body proporstress, undernutrition, prolactinemia, excessive exercise, or tions, breast and genital development, and stigmata of chronic illness. If the ciency is rare but may occur in Kallmann syndrome, which bone age is lower than that consistent with pubertal onset (< 12 years in girls), evaluations should focus on finding the cause of the bone age delay. If growth rate is abnormal, laboratory studies may include a complete blood count, erythrocyte sedimentation A. Constitutional growth delay rate, chemistry panel, and renal and liver function tests to B. Primary ovarian insufficiency hypothyroidism and growth hormone deficiency may also be a. Premature ovarian failure in the setting of delayed bone age since prepubertal levels are (1) Autoimmune disease normally low. Determination of a karyotype should be (2) Surgery, radiation, chemotherapy considered if there is short stature, or any stigmata of Turner c. Congenital hypopituitarism years consistent with onset of puberty and there are minimal c. Functional (chronic illness, undernutrition, exercise, hyperprolevels will distinguish between primary ovarian failure and lactinemia central hypogonadism. Laboratory tests should be directed cell is autonomously activated, resulting in testicular protoward identifying chronic disease and hyperprolactinemia. Leydig In girls with adequate breast development and amenorcell tumors of the testis cause rapid onset of unilateral rhea, a progesterone challenge may be helpful to determine testicular enlargement and physical signs of testosterone if sufficient estrogen is being produced. The exception is girls with an stimulate the Leydig cells to produce testosterone. They have sufficient estrogen but Clinical Findings cannot have withdrawal bleeding. Symptoms and Signs of amenorrhea in girls with sufficient estrogen is polycystic ovarian syndrome. Girls who are estrogen-deficient should In precocious development, increased growth rate and be evaluated similarly to those who have delayed puberty. Testicular size may differentiate central precocity, in which Treatment the testes enlarge, from gonadotropin-independent causes in which the testes usually remain small (< 2 cm in the Replacement therapy in hypogonadal girls begins with estrolongitudinal axis). Tumors of the testis are associated with gen alone at the lowest available dosage. Laboratory Findings eventually the patient may be switched over to a birth control pill for convenience. Progesterone therapy is needed Elevated testosterone levels verify early pubertal status but to counteract the effects of estrogen on the uterus, as unopdo not differentiate the source. Ultrasonography may be useful in detecting hepatic, adrenal, Puberty is considered precocious in boys if secondary sexual and testicular tumors. Treatment of central precocious puberty in boys is similar to Several types of gonadotropin-independent (peripheral) that in girls. Boys should be evaluated for delayed puberty if they have no secondary sexual characteristics by 14 years of age or if more than 5 years have elapsed since the first signs of puberty Treatment without completion of genital growth.

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The chance of later 90% of febrile seizures are generalized anti yeast vegetarian diet buy ketoconazole 200 mg overnight delivery, last less than 5 epilepsy is higher if the febrile seizures have complex feaminutes antifungal shampoo for horses cheap ketoconazole line, and occur early in the illness causing the fever fungus pictures cheap 200mg ketoconazole visa. Other adverse illnesses are most commonly associated with febrile seifactors are an abnormal neurologic status preceding the zures fungus predator animal prey buy 200mg ketoconazole fast delivery. Gastroenteritis fungus head generic 200mg ketoconazole visa, especially when caused by Shigella or seizures (eg antifungal medicine for skin buy 200mg ketoconazole free shipping, cerebral palsy or mental retardation), early Campylobacter, and urinary tract infections are less common onset of febrile seizure (before age 1 year), and a family causes. Even with adverse factors, the risk of study implicated viral causes in 86% of cases. Newer antiepileptic drugs have not but in general do not worsen the long-term outlook. Prophylactic diazepam is also limited by the includes childhood onset of multiple febrile seizures persistfact that a seizure is often the first evidence of fever associing beyond the age of 6 years, and unprovoked (afebrile) ated with an acute illness. Diastat (rectal diazepam gel) can seizures, including absence, myoclonic, or atonic seizures, be used to prevent febrile status epilepticus in the child with and rarely, myoclonic-astatic epilepsy. However, significant Clinical Findings behavioral disturbance is seen in about one third of toddlers treated with phenobarbital. A white count above 20,000/fiL or an extreme left shift infants, the commonly used liquid suspension has a short may correlate with bacteremia. Complete blood count and half-life and causes more gastrointestinal upset than do the blood cultures may be appropriate. Meningitis and encephalitis must be coninfant younger than age 2 years, there is an increased risk of sidered. Thrombocytopenia may occur, particularly neck, stupor, and irritability) may all be absent, especially in in the face of an acute illness. Measures to control fever such as sponging or tepid baths, antipyretics, and the administration of antibiotics for B. Lumbar Puncture proven bacterial illness are reasonable but unproven to prevent recurrent febrile seizures. After controlling the fever and stopping an ongoing seizure, Simple febrile seizures do not have any long-term adverse the physician must decide whether to do a lumbar puncture. In older children, 3/s spike-wave discharges, suggestive should probably be done if the child is younger than age 18 of a genetic propensity to epilepsy, may occur. Longitudinal assessment of adaptive behavior in incidence of recurrent febrile seizures. Only phenobarbital infants and young children with newly diagnosed epilepsy: and valproic acid have demonstrated efficacy in preventing Influences of etiology, syndrome, and seizure control. Bruhn K et al: Screen sensitivity in photosensitive children and Hirtz D et al: Practice parameter: Evaluating a first nonfebrile adolescents: Patient-dependant and stimulus-dependant facseizure in children: Report of the Quality Standards Subcomtors. Hirtz D et al: Practice parameter: Treatment of the child with a Camfield P, Camfield C: Childhood epilepsy: What is the evidence first unprovoked seizure: Report of the Quality Standards for what we think and what we dofi Classification Sabaz M et al: the impact of epilepsy surgery on quality of life in Ninety-five percent of cases of syncope are of the vasovagalchildren. Shostak S, Ottman R: Ethical, legal, and social dimensions of More ominous is cardiac syncope, which often occurs during epilepsy genetics. An obstructive Sillanpaa M, Schmidt D: Natural history of treated childhoodlesion such as aortic stenosis, cardiomyopathy, coronary onset epilepsy: Prospective, long-term population-based study. Hemoglobin should be checked if anemia is suggested by the Verrotti A et al: Intermittent oral diazepam prophylaxis in febrile history. Zaccara G et al: Idiosyncratic adverse reactions to antiepileptic Vasovagal, neurocardiogenic (neurally mediated) drugs. There may be a Nonsyncope mimicker prodrome of dizziness, lightheadedness, nausea, so-called Migraine with confusion or stupor gray-out, sweating, and pallor. After falling, many children Seizure stiffen or have jerking motions when unconscious, a tonicHypoglycemia clonic, anoxic-ischemic seizure mimicking epilepsy. Migraine headache occurs in 5% and 15%, respecrecurrent syncope to confirm a vasodepressive cause and tively, of children at these ages. A more exhaustive classification scheme has been developed by the Treatment consists mostly of giving advice about the benign International Headache Society and modified for use in nature of fainting and about avoiding precipitating situachildren. The patient should be cautioned to lie down if prodroin older children and adolescents. Singh A, Silberbach M: Consultation with the specialist: CardiovasBetween 65% and 75% of children referred to neurology cular preparticipation sports screening. Pediatr Rev 2006;27:418 clinics for consultation regarding headaches have migraine. Verma S et al: Syncope in athletes: A guide to getting them back on Many of these children are referred after they have seen their feet. Approximately 30% of children are referred head-up tilt testing in children: Comparison between isoproterenol after already undergoing one or more neuroimaging tests, and nitroglycerin. Pediatric Migraine without Aura (Common) Pediatric Migraine with Auraa (Rare) Diagnostic criteria Diagnostic criteria A. Bilateral location (frontal/temporal) or unilateral location or brainstem dysfunction 2. The headnormal, a lumbar puncture may be needed to diagnose aches have a pulsatile quality and are located unilaterally or pseudotumor cerebri. A nonspecific prodrome of decreased Treatment or increased appetite and change in mood and temperament Successful treatment of migraine is usually achieved with may precede the headache by hours or days. An aura such as visual scotomata the child is given ibuprofen, 10 mg/kg, followed in 45 is uncommon in children. Additional doses of analgepanied by nausea, vomiting, photophobia, sensitivity to sics rarely provide additional benefit. Occasionally children may have loss of speech, hemipaof isometheptene (Midrin) to ibuprofen may provide more resis, ataxia, confusional states, and bizarre visual distortions reliable relief for some patients. For frequently recurring migraine, nal pain, or recurrent self-limited bouts of ataxia or vertigo as prophylaxis (twice daily or single dose at bedtime) with the early manifestations of migraine. Oral triptans and dihydroergotaIn contrast to tension and migraine headaches, headaches mine have been shown to be effective compared with caused by intracranial disorders or increased intracranial placebo and are safe and inexpensive; most studies have pressure rarely occur in children who are otherwise healthy been done in adolescents. Biofeedback, relaxation therapy, and well and who have completely normal examinations. Termine C et al: Alternative therapies in the treatment of headache in childhood, adolescence and adulthood. Somnambulism and somniloquy (sleep talking) are among a group of sleep disturbances known as disorders of arousal. The episode is relatively brief and ceases sponioral considerations in the treatment of sleep disorders. There is poor recall of the event on waking in the Obstructive sleep apnea and sleep-disordered breathing are morning. Somnambulism may be related to mental activities described in detail in Chapters 17 and 18. Psychopathologic Children (See also Chapters 17 & 18) features are rarely demonstrated, but a strong association Children with sleep apnea frequently have hypertrophied (30%) between childhood migraine and somnambulism has tonsils or adenoids, causing partial airway obstruction. Episodes of somnambulism may be triggered in apnea may also be associated with facial dysmorphism, predisposed children by stresses, including febrile illnesses. No neuromuscular disorders with poor pharyngeal muscle contreatment of somnambulism is required, and it is not necestrol, and conditions causing enlargement of soft tissue in the sary to seek psychiatric consultation. It is Narcolepsy, a primary disorder of sleep, is characterized by characterized by sudden (but only partial) waking, with the chronic, excessive daytime sleeping that occurs regardless of severely frightened child unable to be fully roused or comactivity or surroundings and is not relieved by increased forted. The child has no children with narcolepsy, 18% are younger than age 10, and recall of any nightmare. Most of the time, watchful Acute, Subacute waiting and reassurance of the family are sufficient. Restless Legs Syndrome Decreased level of consciousness (See also Chapter 2) Blurred or double vision Optic disk swelling Restless legs syndrome refers to continuous, bothersome leg Abducens nerve paresis movements occurring at rest and producing unpleasant Chronic paresthesias (sensory symptoms) that often interfere with Macrocephaly Growth impairment restful sleep. Occasionally, anemia (low ferritin) has been Developmental delay noted in adults with the disorder; in these cases improveOptic atrophy ment has occurred with ferrous sulfate treatment. Avoidance Visual field loss of caffeine, nicotine, alcohol, and some drugs (antidepressants, neuroleptics) has helped in adult series. No pediatric medication studies exist; anecdotally, clonazepam, possibly inflammatory, metabolic, toxic, and connective tissue disorders clonidine, and gabapentin are safe options. The diagnosis of pseudotumor cerebri is one of ropinirole, and pramipexole, used in adults, are unproven in exclusion. Venous thrombosis, an underrecognized cause, must be narcolepsy and neurologic disorders. Moore M et al: A review of pediatric nonrespiratory sleep disorMetabolic-toxic disorders ders. An obese teenage girl (or adult) is the typical Chronic otitis media (Lateral sinus thrombosis) phenotype. Homocystinuria/homocystinemia De Lucia D et al: Benign intracranial hypertension associated to blood Vasculitis coagulation derangements. Drug abuse (amphetamines) Lim M et al: Visual failure without headache in idiopathic intracranial Varicella hypertension. Mycoplasma Rajpal S et al: Transverse venous sinus stent placement as treatment Human immunodeficiency virus for benign intracranial hypertension in a young male: Case Fibromuscular dysplasia report and review of the literature. Diabetes Stiebel-Kalish H et al: Puberty as a risk factor for less favorable Nephrotic syndrome visual outcome in idiopathic intracranial hypertension. Dural sinus and cerebral venous thrombosis Thambisetty M et al: Fulminant idiopathic intracranial hypertenCortical venous thrombosis sion. Childhood stroke is any stroke occurring in a Hypercoagulable states Prothrombin gene mutation patient between 28 days and 18 years old. When possible, all children Arterial aneurysm who present with stroke should be transferred to a tertiary Carotid-cavernous fistula Transient cerebral arteriopathy care center that specializes in pediatric stroke management. As a result, the cause of childhood stroke Electrocardiography and echocardiography are useful is increasingly determined, whereas in past studies up to 30% both in the diagnostic approach to the patient and in remained idiopathic. This is particularly important when ongoing monitoring and management, particularly when considering that recurrence risk may be as high as 35%. Chilafter the onset of neurologic deficits is valuable in excluding dren may present with acute hemiplegia similarly to stroke in intracranial hemorrhage. Symptoms of unilateral weakness, sensory disturbance, the early stages of management and in the decision to treat dysarthria, and dysphagia may develop over a period of with anticoagulants. The patient these modalities are sensitive to acute stroke in the initial 3 may also demonstrate disturbances of mood and behavior and hours, when intravenous thrombolytics might be considered. Laboratory Findings and Ancillary Testing transient cerebral arteriopathy, arteriopathy associated with In the acute phase, certain investigations should be carried sickle cell disease, moyamoya disease, arterial dissection, aneuout emergently with consideration of treatment options. When vessel imaging is performed, all major vessels and imaging (see following section). If evidence of fibrobe carried out systemically, with particular attention paid to muscular dysplasia is present in the intracranial or extracranial disorders involving the heart, blood vessels, platelets, red vessels, renal arteriography is indicated. Additional laboratory tests for systemic disorders such Differential Diagnosis as vasculitis, mitochondrial disorders, and metabolic disorPatients with an acute onset of neurologic deficits must be ders are sometimes indicated.

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