By F. Avogadro. Briar Cliff University.

The most important diagnoses to be considered in the differential diagnosis of »growing pains« are tumors and inflammation buy cheap cabergoline 0.25mg on line. If the pains occur alternately on the right and left sides, and if the child’s age is typical and the knees are clinically normal (normal range of motion, no tenderness, no red- ness or swelling), no further diagnostic investigations are required, i. Nor will any abnor- back disorders, we should not completely disregard this mal findings be detected by other imaging procedures if aspect. If the pains consistently occur on one side, a x-ray is always indicated, and a bone scan is also appro- 3. In addition to the pain, children at Both sides are alternately affected. If drugs need to be prescribed, an anti-in- »Growing pains« are a little investigated and uncertain flammatory ointment is better than an analgesic since the phenomenon that occurs during early childhood. Chil- physical contact involved in massaging provides another dren aged between 3 and 8 wake up during the night and opportunity for showing affection. The oral administra- complain of pain, usually in the area of the knee, but also tion of magnesium also appears to produce a beneficial occasionally in the lower leg or foot. Definition The idea that growth is responsible for the symptoms is Distinctly exertional pain around the patella (usually on not completely convincing since growth remains rela- the medial rather than the lateral side) that occurs pre- tively constant during early childhood and does not dominantly during adolescence and usually disappears occur in »spurts« as parents repeatedly assume. In the early 1970’s, when the era of arthroscopy was just be- ginning, irregularities of the retropatellar cartilage were often seen in patients with anterior knee pain. Doctors concluded that this was the cause of the pain and ac- cordingly named the condition »chondromalacia of the patella«. It subsequently emerged, however, that such irregularities also frequently occur in patients without any form of retropatellar pain (who were arthroscopied for completely different reasons) and that these cannot therefore explain the symptoms. Based on the epide- miological findings, the following tentative conclusions can be drawn in respect of the etiology: The pain occurs during the pubertal growth spurt, is particularly severe when retropatellar pressure is high (walking downhill), and particularly affects tall (asthenic) girls with pro- portionately weak muscles. An imbalance must exist, therefore, between the rapidly rising retropatellar pres- sure situation resulting from the growing lever arms on the one hand and muscle (and ligament) control on the other. We can now say for sure that a »disorder« of the retropatellar cartilage is not present in most patients and that the term »chondromalacia« should not therefore be used (apart from a few arthroscopically confirmed, usu- Charlie had no anterior knee pain because he turned outwards to make his knees point straight ahead; the problem occurs primarily ally posttraumatic, cases).

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From Brooks DN and McKinlay WW cabergoline 0.5 mg fast delivery, Evidence and Quantification in Head Injury: Seminar notes. In this study, the sign of responsiveness used was evidence of the patient following commands Other Indicators of Outcome after TBI Include: Age – Children and young adults tend to have a generally more positive prognosis than older adults. However, young children (< 5 yrs) and older adults (> 65 yrs) have greater mor- tality – Katz and Alexander (1994): Age ≥ 40 correlates with worse functional outcome when compared with patients < 40 Rate of early recovery reflected in serial disability rating scales (DRS): found to be predic- tive of final outcome Pupillary reaction to light: – 50% of patients with reactive pupils after TBI achieve moderate disability to good recovery (in DRS scale) vs 4% with nonreactive pupils Time – Most recovery usually occurs within the first 6 months postinjury Postcoma use of phenytoin: – Long-term use of phenytoin has been reported to have adverse cognitive effects (neu- robehavioral effects in severe TBI patients compared to placebo group) HEAD INJURY PREDICTOR SCALES AND TESTING Prognosis in Severe Head Injury TABLE 2–4 Predicative Indicator Poorer Better Glasgow Coma Scale score < 7 > 7 CT scan Large blood clot; massive Normal bihemispheric swelling Age Old age Youth Pupillary light reflex Pupils remain dilated Pupil contracts Doll’s eye sign Impaired Intact Caloric testing with ice water Eyes do not deviate Eyes deviate to irrigated side Motor response to noxious Decerebrate rigidity Localizes defensive gestures stimuli Somatosensory evoked potentials Deficient Normal Posttraumatic amnesia length > 2 wks < 2 wks (Reprinted with permission from Braddom, RL. Absent awareness of self and environment; patient may open eyes; absence of cortical function as judged behaviorally; characterized by the presence of sleep-wake cycles 3 Severe disability Patient unable to be independent for any 24-hour period by reason of residual mental and/or physical disability 4 Moderate disability Patient with residual deficits that do not prevent independent daily life; patient can travel by public transport and work in a sheltered environment 5 Good recovery Return to normal life; there may be minor or no residual deficits Widely used scale; documented correlation between acute predictors of outcome and GOS score at 6 months and 12 months Cons: – In the GOS, categories are broad; scale not sensitive enough – Not real indicator of functional abilities (Continued) 60 TRAUMATIC BRAIN INJURY Disability Rating Scale (DRS) TABLE 2–6 1. Motor Response 0 Spontaneous 0 Oriented 0 Obeying 1 To Speech 1 Confused 1 Localizing 2 To Pain 2 Inappropriate 2 Withdrawing 3 None 3 Incomprehensible 3 Flexing 4 None 4 Extending 5 None 4. Employability *Note: measuring cognitive skills only in these categories. The change as a percentage of total score was greater for the CRS than for the GCS or DRS (Horn and Zasler 1996) Neuropsychological Testing Prior to the development of the CT Scan, neuropsychological assessment was targeted at determining whether a brain lesion was or was not present, and, if present, discerning its location and type This diagnostic approach supported the development of the Halstead-Reitan Neuropsychological Battery (HRNB). This battery was initially designed to assess frontal-lobe disorders by W. Halstead (1947) and subsequently used by Reitan (1970 1974), who added some tests and recommended its use as a diagnostic test for all kinds of brain damage. Most examiners administer this battery in conjunction with the WAIS-R (Wechsler Adult Intelligence Scale—Revised) and WMS (Wechsler Memory Scale) or the Minnesota Multiphasic Personality Inventory (MMPI) Wechsler Adult Intelligence Scale—Revised (WAIS-R): eleven subtests (6 determine verbal IQ and 5 determine performance IQ), WAIS-R is the most frequently used measure of general intellectual ability. It is the most widely and thoroughly researched objective measure of personality. MEDICAL COMPLICATIONS AFTER TBI Posttraumatic Hydrocephalus (PTH) Ventriculomegaly (ventricular dilation) is common after TBI , reported in 40%–72% of patients after severe TBI. It should remain > 60 mmHg to ensure cerebral blood flow CPP = MAP—ICP Fever, hyperglycemia, hyponatremia, and seizures can worsen cerebral edema by ↑ ICP Indications for Continuous Monitoring of Intracranial Pressure and for Artificial Ventilation 1. Patient in coma (GCS < 8) and with CT findings of ↑ ICP (absence of third ventricle and CSF cisterns) 2. Severe chest and facial injuries and moderate/severe head injury (GCS < 12) 4.