4 December Diagnoses…With a Twist

I’m not quite ready to write my “2019 year end” blog entry yet, but I am kind of in a mood to take stock and sum some things up, categorize a few items. Do you ever get this way—you want to tie loose ends up, make a final list, etc. It’s sort of a gratifying exercise in terms of giving a subject closure, and I’m feeling like doing it right now, so maybe it would be useful to list out some of the “trends with a twist” I’ve been seeing lately at work. These are conditions that are fairly routine but can often have some nuance added to them that either make them seem a little unusual, or maybe even a little bit scary. Alright, here we go:

Plenty of pneumonia

Many people panic at hearing the word “pneumonia.” I mean, I get it—lots of people used to die of pneumonia back in the early 20^th century and before, and sadly some still do today, but all pneumonia really means is an infection in the lower, smaller airways in the lungs. Community acquired pneumonias are in fact pretty common, pretty treatable, and can be pretty un-dramatic. I’ve written about pneumonia elsewhere, but it’s what I think about when I see a child with a fever who is coughing, has some respiratory distress in the form of increased work of breathing and/or rapid respiratory rate, and even abdominal pain. Pneumonias can be caused by both viruses and bacteria, so sometimes it can be a challenge to differentiate them, but for whatever reason there seems to be a fair amount of it going around. Since the pneumococcal vaccine began, we have been seeing less severe sickness due to that germ, but there are plenty of other microbes that can cause pneumonia, and recently there’s been a run on it.

The twists –

1. It can be treated as an outpatient (with oral antibiotics if thought to be due to a bacterial cause).
2. An x-ray is not always necessary in order to make the diagnosis; and
3. Hydration is a key component in recovery.

Cuts that could either be fixed with stitches or glue; tough call sometimes

It would be so great for everyone involved if we could just superglue every kid that got a cut. Can you imagine—no need for stitches at all—just clean up the wound and stick those edges together and voila! Of course ask anyone who has used the glue on either a larger, or deeper area, or area of skin tension like a chin or joint and had it re-open and they will tell you that maybe the skin adhesive isn’t always the best way to go. In some instances it works great, and there are always those few who could probably go either way. I seem to the lucky gal who gets lots of those, and even after all these years sometimes it can be a tough decision. What I will say about this is that it is no fun to have a laceration re-open, because most of the time it cannot or should not be re-closed again due to risk of infection, and so if your healthcare professional suggests that stitches is likely the way to go, I would suggest that you go with that recommendation. As definitive a closure as possible the first time is the best way to go.

The twists –

Sometimes that works great with glue; sometimes stitches are the better choice. Just keep that in mind. A few things to know about this—

1. You know your child. If (s)he is one with tremendous energy and curiosity and is likely to have difficulty leaving the repair alone, sturdier stitches might be a smarter choice.
2. Definitely follow instructions on healing.
3. Pay attention to signs of infection- increased pain, warmth and redness, perhaps pus drainage. If you see any of this, get it checked out early. Initiating treatment early for a wound infection can really impact final outcome.

Sore throats that aren’t strep

Here’s another scenario I understand completely- child gets brought in for strep test the moment they complain of a sore throat. Many of these kids are frequent strep infection flyers and knowing and treating early has big payoff since most people feel better within about 24 hours of starting antibiotics for strep throat. I need to remind everyone here that not every sore throat is caused by strep- in fact many sore throats are caused by viruses and can look very similar and red and angry just like they do when colonized with strep. Still, I get lots of shocked looks when I report that the strep test is negative and no antibiotics are needed. But this is why we need to do the swab and run the test- so we are treating appropriately. Sometimes the rapid preliminary test does eventually yield a positive final test, but most of the time it doesn’t, so it makes sense to go with the initial result at first. And let me tell you, I see A LOT of negative strep tests. Viruses cause sore throats.

The twists –

1. Hydration just might be the most crucial key (said with emphasis) to managing any sore throat: dry mucus membranes that line the throat just hurt worse, and a vicious cycle ensues whereby the pain decreases the desire and drive to drink fluids, and more dehydration increases pain, etc. Don’t get in the cycle.
2. As a general rule it’s not wise to take antibiotics for a sore throat “just in case”- without getting a test to be sure. Antibiotic resistance and stewardship is at play here, and you don’t want to wind up with a more serious infection elsewhere in the body because you wiped out your good bacteria in your gut, for example.
3. Give the pain reducer medicine. Gargle the salt water. Do all the things to soothe the discomfort. So many people I see respond with “nothing” to my question: “What are you doing to try to help yourself feel better?”

Problems attributed to cold weather

The cold weather doesn’t just bring injuries due to slips and falls on icy surfaces; in fact we can rely on cold weather for doing wacky things to our skin and causing us to wheeze as well. I’m seeing more children with eczema flares right now—remember that the best defense is a good offense here—and the best way to keep the eczema symptoms to a minimum is to keep that skin lubricated with a good barrier ointment. For all the zillions of kids who wheeze more during cold temperatures, discuss with your healthcare provider whether or not a preventive inhaler medicine would be helpful during this season. Here’s the twisty stuff I see related to the weather.

The twists –

1. Some kids will get really red cheeks that can look infected from being outside in the cold for prolonged periods. This is called “cold panniculitis” and while it may look dramatic, is harmless and will go away on its own. One way to avoid it is by putting on an ointment like Vaseline on the cheeks prior to going outside.
2. Young people who shovel snow get muscle strains but fortunately don’t usually have heart attacks while doing it. There’s lots of media about the risk for adults, but kids can get chest pain after shoveling and it is mostly due to non-cardiac causes, like muscle strains or even costochondritis, an inflammatory condition in the joint between the ribs and sternum. All managed with pain control medicines like ibuprofen and similar.
3. I don’t really have a third I don’t think. Just wanted it in here for symmetry. Snow days are fun, but for the life of me I can’t seem to predict when the school administrators in my area will call the day, a 2 hour delay, or not at all. Anyone with insight into this process, please share for all of our benefit.

So those are a few highlights from recent patient traffic coming through the PM Pediatrics offices. In addition to those, I’ll add that medical problems typically always seem worse at night and on weekends during off hours. That might be the most frustrating twist of all, but it feels like it’s a regular one.

Of course, that’s one of the main reasons I’m in the business or emergency and urgent care medicine: we’re always available when the twists arise