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H. Domenik, M.A., M.D.

Vice Chair, University of Hawaii at Manoa John A. Burns School of Medicine

He has no skin rashes or anal fissures, and the remainder of his physical examination findings are normal. Dietary protein induced colitis typically presents in the first few months after birth, with a mean age at onset of 2 months. The diagnosis of this condition is based primarily on the history and physical examination. Anal fissures, another common cause of small amounts of rectal bleeding in otherwise healthy young infants, should be ruled out by physical examination. Further evaluation is not necessary for suspected dietary protein-induced colitis. However, if there are other signs or symptoms, such as vomiting, poor weight gain, large amounts of blood in the stool, fever, or other signs of infection, alternate diagnoses should be considered. Additional evaluation may be required if the symptoms do not resolve with dietary elimination of the offending protein or if additional symptoms occur. Treatment for dietary protein-induced colitis is elimination of the offending protein. Because this condition is a response to the protein rather than the carbohydrate component of the feeding, changing to a lactose- free formula would have no effect on the symptoms. Because soy is often a trigger for the condition, changing to soy formula is not appropriate. Dietary protein-induced colitis is not an immunoglobulin E (IgE)-mediated condition, therefore performing serum-specific IgE test is not warranted. Symptoms that suggest IgE-mediated cow milk allergy, such as wheezing and the involvement of other organ systems besides the gastrointestinal system (eg, urticaria), typically occur immediately after milk ingestion. Endoscopy and biopsy are generally reserved for infants whose symptoms worsen after maternal cow milk and soy elimination, or if the bleeding does not resolve. Normal frequency and consistency can vary widely between individual infants and over time. Soon after birth, breastfed infants typically have more frequent, less formed, sometimes mucous-containing stools compared with formula-fed infants. Most breastfed infants average about 4 stools per day at 1 month of age, whereas formula-fed infants typically have 2 to 3 stools per day. Stooling frequency may occur as often as after every feeding soon after birth, to as infrequently as every few days as the infant matures. He reports a gradual onset of poor appetite, fatigue, joint pain, nausea, and abdominal pain. The disease is endemic in Southeast Asia, Africa, Central Europe, and Eastern Europe. In individuals immunized with hepatitis B vaccine, antibody to hepatitis B surface antigen alone is present. The clinical spectrum of chronic hepatitis B infection in children can vary from an asymptomatic carriage state (in perinatally infected children) to jaundice and elevation of serum alanine transferase levels (in older infected children and adolescents). Treatment is recommended to reduce the risk of disease progression to cirrhosis and subsequent development of hepatocellular carcinoma. Treatment of chronic hepatitis B infection in childhood can be challenging because of the lack of guidance on initiation of antiviral agents and duration of treatment. The local or state health department must be notified of all children with positive hepatitis B surface antigen test results. The child described in this vignette has IgG to the hepatitis A virus, which indicates immunization or past infection. The presence of hepatitis B e antigen suggests high viral replication and increased risk of hepatitis B virus transmission. Screening for chronic hepatitis B virus infection is recommended for international adoptees, refugees, and immigrants. The boy describes episodes of nausea and vomiting that occur every 4 to 5 weeks with 9 to 15 episodes of nonbloody, nonbilious emesis followed by a return to baseline good health over a 24-hour period. The family reports no recent travel, head trauma, cannabis exposure, food triggers, or illnesses preceding the emesis. The boy has been seen in the emergency department on 3 different occasions, where he was diagnosed with an acute viral illness and treated with intravenous fluid hydration and nausea medication.

The specific clinical aspects will also include an appropriate preventive program specific to the individual needs and risk factors of each pediatric patient. Nitrous oxide-oxygen sedation supervised by an instructor licensed to administer it. Other methods that may positively affect the dentist-patient relationship as approved in writing in the patient treatment chart after informed consent with the parent/legal guardian. Physical restraint would be used only in emergency situations and/or for very limited procedures such as during the administration of local anesthesia. Instruction regarding the etiology of dental disease in simple terms that both the patient and parent/legal guardian can readily understand. Pediatric Dentistry Quality Indicators and Description of Measurement Quality Indicator Pediatric patients had a current health history form signed by his/her parent or legal guardian prior to the start of treatment. Pediatric patients who had a complex medical history had appropriate documentation (alerts) in the patient record prior to the start of treatment. Pediatric patients had his/her treatment plan appropriately signed by his/her parent or legal guardian prior to the start of treatment. Moderate and high caries risk patients had sealants placed on their 1st molars within 4 years of eruption Pediatric patients had an appropriate topical fluoride treatment done in conjunction with his/her oral prophylaxis. Pediatric patients had an occlusal examination documented in the dental chart at their previous routine examination Pediatric patients had an appropriate recall prophy date established based upon his/her caries index documented in the progress notes Measurement Medical history at initial appointment. This periodontal examination will be based on patient history and the use of appropriate diagnostic aids which include, by may not be limited to , the following: current radiographs, pocket probing, furcation evaluation, keratinized tissue assessment, gingival recession and tooth mobility. Oral hygiene homecare will also be evaluated in order to facilitate the development of appropriate individualize patient-specific oral hygiene instruction. Measurement % of comprehensive care patients who had periodontal examination at initial appointment. These services include, but may not be limited to , the following: plaque control, mechanical debridment, oral health counseling, caries control, appropriate use of fluorides, sealants, diet counseling and athletic mouth guards. High or Extreme Risk for caries (Cambra) received fluoride therapy or fluoride prescription. Comprehensive treatment plans will be developed that provide optimal function, esthetics, and length of service and offer reasonable alternatives when appropriate. Active disease of hard and soft tissues will be controlled prior to initiating definitive restorative care. The comprehensive treatment plan will be sequenced, written in a format that the patient can understand and be within the scope of the predoctoral program. Prior to commencement of comprehensive treatment, the patient will be made aware of his/her financial responsibilities, the approximate total treatment time and visit intervals of the plan, and the appropriate follow-up in the event of a dental emergency. The comprehensive treatment plan will be signed and dated by the patient, the attending faculty member and the student provider prior to its initiation. All patient procedures will be accomplished utilizing standard universal precautions to prevent microbial contamination/cross contamination. Whenever possible, intra-coronal tooth restorations and cementations will be accomplished using isolation from surrounding soft tissue, saliva, and other causes of intra-oral moisture using the dental dam. When the dental dam cannot be placed, as in the cementation of a fixed prosthesis, appropriate absorbents and intra-oral evacuators will be used. The decision to replace missing teeth is based upon clinical findings, occlusal considerations, the ability of the patient to maintain the prosthesis, the prognosis for drift and/or super eruptions, teeth position and patient preference. The diagnosis and case history/treatment plan will be reviewed and approved by an attending faculty member prior to commencement of the case. Overdentures, immediate dentures and/or implants may be considered for the partially edentulous patient for whom the remaining teeth are no longer able to support a removable partial denture. Existing dentures will be evaluated for correction such as reline, rebase, occlusal adjustment, etc. Comprehensive care patients started definitive treatment within 3 weeks of signing approval of his/her sequence comprehensive treatment plan. Comprehensive care patients who received treatment for a single unit crown had it completed/cemented within 4 clinical appointments (including crown preparation) and within 2 months of initial crown preparation. Comprehensive care patients receiving prosthodontic treatment for a 3 to 5 unit fixed bridge had it completed/cemented within 5 clinical appointments and within 3 months of initial tooth preparation.

Careful analysis of the gait is critical in creating a correct differential diagnostic list. Once you establish if the patient is ataxic or not, the selection of diagnostics tests will be completely different. The peripheral patient or metabolically weak patient requires other diagnostics procedures (eg. Postural reactions test the same neurological pathways involved in the gait, proprioceptive and motor pathways. Their main value is detecting asymmetry that may not be obvious during the observation of the gait. It is important to remember that postural deficits should be interpreted in the light of gait analysis. Systemic weakness, fever, orthopaedic disease and fear can affect the knuckling response. Proprioceptive pathways are often compromised on the early stages of neurological disease so the deficits may be detected prior to observing sings of weakness. Once all the elements of the neurological exam are combined, it can be establish if the deficit seems relevant for the patient that is been evaluated. Cortical lesions are usually characterized by postural deficits that are opposite to the side of the lesion. In an patient suspected to have a cortical lesion the menace response, and nasal septum are evaluated carefully for symmetry to establish if there are contralateral deficits on these tests as well as proprioception. The most relevant information that need to be determined is if the reflex is present or absent. It is important to keep in mind that when there is alteration of the muscle mass and extreme rigidity, it can be hard to establish if the reflex is present. In this case the rigidity should be overcome by flexing the limb slowly multiple times. When evaluating the withdrawal reflex in these spastic limbs, it is recommended to start pinching the toe once the limb is successfully flexed. An absent reflex indicates that the lesion could be present in the peripheral nerve, nerve root, spinal segment, neuromuscular muscle and muscle. Therefore, trauma patients should be evaluated sequentially to determine if spinal shock is present and affecting the results of the examination. If the gait analysis indicates that there is proprioceptive ataxia a spinal lesion is investigated. The next step to localize the area affected is determined by the limbs affected and the presence or absence of reflexes. Abnormalities of the C6-T2 spinal segments manifest with involvement of all 4 limbs and decreased reflexes on the forelimbs. Lesions that compromise the T3-L3 region tend to present with abnormalities of the hind limbs only but intact reflexes. Lastly spinal lesions affecting the L4-S2 enlargement will have decreased reflexes and only the hind limbs will be affected. Muscle tone is a valuable element to corroborate the suspected lesion localization. Lesion affecting the C6-T2 and L4-Ss enlargements can present with decreased muscle tone. One hand should be placed under the abdomen to detect tensing of the abdominal muscles as the affected area is palpated. Often cervical pain can be detected by observing the posture of the patient and the presence of muscle cervical fasciculations. However, is not uncommon that a dysphoric patient, presenting with brain disease such as brain tumor, encephalitis or hydrocephalia will vocalize constantly as a manifestation of dysphoria and not pain. It is believed that stretching of the meninges could be responsible for pain in these patients. Mississauga-Oakville Veterinary Emergency Hospital, Oakville, Ontario Movement disorders in people. Recently awareness about similar conditions in veterinary medicine has gained interest and classification of movement disorders is starting to advance rapidly. Contrary to what was believed in the past, not all episodic events in veterinary medicine are the result of seizure activity.

Causes include familial, hyperthyroidism, precocious puberty, and growth hormone excess. A moist washcloth or gauze pad may be used initially, and a soft toothbrush may be used as early as tolerated. Dental floss to remove plaque from between teeth should be initiated when tight contact exists between teeth. Sources of fluoride include fluoridated water, fluoride supplements, and fluoride toothpaste. Fluorosis affects permanent teeth and leads to abnormalities in dental enamel and dentin. Effects are cosmetic only and include white streaks, pitting, or brown-gray staining. The most critical time for dental vulnerability to excess fluoride is between 2 and 4 years of age. Although care must be taken to prevent fluorosis, fluoride supplementation remains important for the following children: 1. Exclusively breastfed children older than 6 months, as breast milk contains little fluoride. Occasionally infants are born with teeth or have teeth that erupt within the first month of life. More than 90% are primary teeth that erupt early and < 10% are supernumerary teeth (teeth in excess of usual number). Etiology is often unknown but may be caused by exposure to environmental toxins or may be familial. Most frequently associated with a history of falling asleep with a nipple (breast or bottle) in the mouth or in children who breastfeed excessively or who carry around a bottle as a habit. It does not appear in the oral cavity until teeth erupt, and children acquire this bacteria from colonized parents or siblings. A permanent tooth that has been traumatically avulsed may be re-implanted if the avulsed tooth is placed into the socket rapidly. Extraoral time is the most important factor affecting the prognosis for successfully re-implanting a tooth. A dry-stored tooth has a poor prognosis for re-implantation, even after only 30 minutes. Management includes gentle rinsing of an avulsed tooth with saline, placement into the socket, and referral to a dentist. Developmental Screening One of the most important preventive measures of well child care is assessment of developmental milestones. Development is therefore assessed at each well child visit from infancy through school age. Anticipatory guidance is patient and parent education and is provided during each well child visit. Age-appropriate anticipatory guidance topics for children from birth to 5 years of age are detailed in Table 1-5. A 6-month-old girl has been noted to fall off her growth curve and now is < 5% for her age. Prenatal onset of inadequate weight gain that persists in the postnatal period (C).