one response with now reference to each discussion.
discussion 1- Pathophysiology: Scoliosis is defined as a lateral curvature of the spine that occurs in a variety of conditions, defined commonly as >10 degrees of curvature (as measured by the Cobb angle) (Scherl & Hasley, 2022). It can be classified into three categories: idiopathic, congenital, and neuromuscular scoliosis. Idiopathic scoliosis is a diagnosis made when all other causes are excluded and comprises about 80% of all cases with adolescent idiopathic scoliosis being the most common type of scoliosis, often diagnosed during puberty (American Association of Neurological Surgeons [AANS], 2022). Congenital scoliosis is caused by asymmetry secondary to congenital vertebral anomalies such as hemivertebrae or congenital fusion, often associated with other organ system abnormalities (Scherl & Halsey, 2022). Neuromuscular scoliosis occurs secondary to neurological or muscular diseases such as cerebral palsy, spinal cord trauma, muscular dystrophy, and spina bifida. This type of scoliosis is more progressive than idiopathic scoliosis and often requires surgical intervention (AANS, 2022). Syndromic scoliosis is related to VACTERL (vertebral, anal atresia, cardiac defects, tracheoesophageal fistula, renal abnormalities, and limb defects) and neurofibromatosis (LeFever & Menger, 2022)
Epidemiology: Scoliosis affects 2-3 percent of the population or approximately 6 to 9 million people in the United States. It can develop during infancy or early childhood, but the average age of onset for scoliosis is 10-15 yrs. old, affecting boys and girls equally. 8 x as many females are likely to progress to curve that needs treatment. Scoliosis patients make at least 600,000 visits each year to private physician offices, with approximately 30,000 children being fitted with a brace and 38,000 undergoing spinal fusion surgery (AANS, 2022).
Physical Exam Findings: Exam findings are done by exposure to the trunk and back to envision the iliac crest and posterior and anterior iliac spines. Upon inspection, findings of scoliosis may include curvature of spine with thoracic or lumbar asymmetry; differences in the level of the shoulders or scapulae; asymmetry of the waistline; asymmetry in the distance that the arms hang from the trunk; and head shifted to one side and not centered over the sacrum. It may be seen by performing the Adams forward bend test and having ≥ 10-degree Cobb angle (Scherl & Halsey, 2022).
Differential Diagnoses and Rationale:
Nonstructural curves:
Poor posture, abdominal muscle weakness, psychological problems (hysteria), leg-length discrepancy, paravertebral muscular spasm, or visceral pain.
All of these are often benign and usually correct with postural changes or treatment of the underlying condition and can all mimic scoliosis in their presentation (Chin et al., 2021).
Structural curves:
Idiopathic scoliosis: a diagnosis of exclusion, either early onset or late onset. Need to rule out central nervous system causes with MRI, such as syringomyelia, Arnold-Chiari malformation (displacement of brain stem into the foramen magnum) or a tethered cord (present with 17% of early-onset scoliosis) (Chin et al., 2021).
Congenital scoliosis: from anomalies in developing vertebrae, may be present in Klippel-Feil syndrome, Goldenhar syndrome and Jarcho-Levin syndrome (Chin et al, 2021).
Neuromuscular scoliosis: result from upper or lower motor neuron disorders, such as cerebral palsy, poliomyelitis, viral myelitides, spinal muscular atrophy, and arthrogryposis, as well as Duchenne and Becker muscular dystrophy. Neurofibromatosis is commonly presented as scoliosis (Chin et al, 2021).
Osteochondrodystrophies: characterized by short stature with spinal deformity manifest in this group. (Chin et al, 2021).
Metabolic diseases: osteogenesis imperfecta, rickets, and homocystinuria may cause scoliosis and kyphosis (Chin et al, 2021).
Iatrogenic deformities: from irradiation or surgery such as thoracotomy, rib resection, etc. may affect growth of the vertebral epiphyseal plate, causing scoliosis or kyphosis (Chin et al, 2021).
Management plan to include diagnostic testing, medications if applicable, follow-up plans, and referrals if needed
X-rays are the primary imaging modality that allows visualization of deformity and measures angular deformity (LeFever & Menger, 2022).
Early-onset scoliosis (EOS) imaging helps provider understand the three-dimensional nature of the deformity with ultra-low dose radiation pulse in a standing or upright position (LeFever & Menger, 2022).
CT allows to see the bony vertebral anatomy in detail and ribs (LeFever & Menger, 2022).
MRI determines abnormalities of the spinal cord. It can detect common co-presentations such as a Chiari, a synrix, or tethered cord (LeFever & Menger, 2022).
Treatment:
Stop progression by: use of spinal bracing, surgery to fix scoliosis with various methods
Referral to a specialist (neurosurgeon, oncologist, orthopedic surgeon, neurologist) for those with clinical or radiographic findings suggestive of congenital or neuromuscular scoliosis (Scherl & Hasley, 2022)
Follow-up with primary provider after seeing specialist.
References
American Association of Neurological Surgeons. (2022). Scoliosis. Retrieved December 1, 2022, from https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Scoliosis
Chin, K. R., Price, S., , & Zimbler, S. (2021). A guide to early detection of scoliosis. Contemporary Pediatrics. https://www.contemporarypediatrics.com/view/guide-early-detection-scoliosis
LeFever, D., & Menger, R. P. (2022). Infantile and juvenile scoliosis. StatPearls [Internet]. Retrieved December 2, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK519498/#_NBK519498_pubdet_
Scherl, S. A., & Hasley, B. P. (2022). Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis. UpToDate. Retrieved December 1, 2022, from https://www.uptodate.com/contents/adolescent-idiopathic-scoliosis-clinical-features-evaluation-and-diagnosis?search=scoliosis%20children&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
discussion 2-Microcytic Anemia
Pathophysiology
Microcytic anemia is when the mean corpuscular volume (MCV) is low, or below normal MCV levels of 80-100 fL. In other words, the red blood cells are small (Maner, et al, 2022). This is usually a result of a deficiency in iron storage and or synthesis in the red blood cell, resulting in a smaller cell (Maner, et al, 2022). Causes for a decrease in smaller sized red blood cells can include: iron deficiency from diet, blood loss, or intoxication of lead, malabsorption of iron, an inherited blood disorder, or a result of an inflammatory state such as in chronic disease (Chaudhry & Kasarla, 2022).
Physical exam findings
Irritable, restless.
Pica-a child may want to eat clay or dirt.
Anorexia
Developmental delay.
May be asymptomatic, as in the case with Beta Thalassemia.
Jaundice
(Maaks, et al, 2020, p 748).
Differential diagnoses and rationale
Iron deficiency related to blood loss, dietary deficiency, or bowel disorders.
Most frequent cause of anemia in children (Maaks, et al, 2020, p 746).
Can be related to excessive cow’s milk ingestion (Maaks, et al, 2020, p 748).
Can be due to Excessive menstruation
9% of girls develop iron deficiency (Maaks, et al, 2020, p 748).
Can be due to malabsorption disorders such as Celiacs (Maaks, et al, 2020, p 748).
Consider food insecurity in low-income families.
Thalassemia
The body cannot synthesize hemoglobin.
Alpha thalassemia trait: microcytic anemia with normal Hgb F and HgbA2 levels.
Beta thalassemia minor: insufficient alpha chains. These patients are often asymptomatic and do not require treatment.
Beta Thalassemia major: degradation resulting in no B chains and they require frequent transfusions. These children will have elevated HgbF and HgbA2 levels.
Chronic inflammatory disease
This can result in blood loss and disordered hemoglobin.
Lead intoxication
You will see a low reticulocyte count and elevated blood lead level (Uptodate, 2022).
Copper deficiency
Not very common, but can be seen in malabsorption conditions.
Hereditary pyropoikilocytoses
An inherited blood disorder.
Hemoglobin CC
(Maaks, et al, 2020, p. 746).
Management plan to include diagnostic testing, medications if applicable, follow-up plans, and referrals if needed
Screening
Every child should be screened at 12 months for anemia with a hgb level (Maaks, et al, 2020, p 748). If they are anemic, then you can perform additional testing to evaluate the type of anemia such as a CBC-D to evaluate the MCV, RDW, and Reticulocyte levels. With microcytic anemia, there will be a low MCV. A TIBC will be increased and a transferrin level with be decreased with iron-deficiency anemia (Chaudhry, & Kasarla, 2022). In order to differentiate between iron-deficiency anemia and thalassemisa, review with Red cell distribution width (RDW). With iron-deficiency, the RDW will be elevated, whereas it will be in normal limits with Thalassemias (Uptodate, 2022).
If a child is at risk for lead poisoning, they should be screened at 9-12 months of age and at 24 months (Maaks, et al, 2020, p 748).
Referrals
Referral to a hematologist if: they Hgb level is 7 g/dL or less or if they have any red flags such as pancytopenia, fever, and bruising.
Referral to nutritionist if they have dietary restrictions, for example due to celiac or choosing to be vegan.
Management: correct the offending factor if there is one- such as excessive menstruation, celiac disease or lead intoxication.
Initial management for iron-deficient anemia: begin Iron supplementation and repeat Hgb level in one month, with the goal of an improvement of 1-2 /dL (Maaks, et al, 2020, p 748).
Breast fed babies should take iron supplements starting at 4 months of age, when the maternal storage is decreased (Maaks, et al, 2020, p 750).
If iron supplementation does not improve the anemia, then refer to hematologist as they may have a Thalassemia (Maaks, et al, 2020, p 751).
For thalassemia: collaboration with a hematologist as they patient may require no treatment or transfusions (Maaks, et al, 2020, p 752). If they require frequent transfusions, then there is the risk of iron overload requiring chelation therapy (Maaks, et al, 2020, p 752).
References
Chaudhry HS, Kasarla MR. (2022). Microcytic Hypochromic Anemia. StatPearls. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK470252/
Maaks D. L. G., Starr N., & Gaylord N. (2020). Burns’ Pediatric Primary Care. [Pageburstls]. Pp 746-752. Retrieved from https://pageburstls.elsevier.com/#/books/9780323581967/
Maner BS, Moosavi L. Mean Corpuscular Volume. (2022). In: StatPearls.
Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK545275/
UptoDate. (2022). Approach to the Child with Anemia. Retrieved from https://www.uptodate.com
/contents/approach-to-the-child-with-anemia
