BIOSOFT HELP FILES

1)      Hydrocele

2)      Hernias

3)      Acute epididymal-orchitis – exclude gonococcal infections (See under genital discharge)

4)      Testicular Torsion – thunderclap scrotal pain, early pubertal, diffuse scrotal tenderness, teste located high in the scrotum, swollen diffusely tender testes, transverse rotation of the testes, anterior epididymis, thickened spermatic cord, past recurrent mild similar episodes, cremasteric reflex negative (retraction of scrotum and testicle with ipsilateral stroking of the inner proximal thigh), Tx – Surgical exploration

5)      Appendiceal Torsion – moderate pain developing over a few days, prepubertal, point tenderness at the upper pole of the testis, cremasteric reflex positive, Mx – bed rest an scrotal elevation

6)      Epididymitis - moderate pain developing over a few days,  adolescence, point tenderness over the epididymis., cremasteric reflex positive, Prehn’s sign positive (scrotal elevation relieves the testicular pain), Mx - Antibiotics

1)      Acute epididymitis – painful swelling of epididymis, tender swelling of epididymis, unilateral testicular pain, tender testes, hydrocele, palpable eoididymis, tendere swollen spermatic cord, in sexually active males associated with asymptomatic urethritis,  but laboratory evidence of urethritis seen, non-STD epididymitis is associated with UT instrumentation, surgery, systemic disease, immunosuppression, Gram stain of urethral secretions show more than 5 WBC  per oil immersion field, WBC with gram negative intracellular diplococci in case of gonococcal infection, first void urine leucocyte esterase test positive, first void urine sediment microscopy shows more than 10 WBC high power field, urethral swab specimens for culture of N. gonorrhoeae and C. trachomatis positive if acute epidicymits is of STD origin, color duplex doppler ultrasonography sensitivity 70% specificity 88%, Tx – for gonococcal or chlamydial infections Ceftriaxone 250 mg IM single dose AND Doxycycline 100 mg PO bid for 10 days, bed rest, scrotal elevation, analgesics, for epididymitis due to enteric organisms Ofloxacin 300 mg PO bid for 10 days OR Levofloxacin 500 mg PO once daily for 10 days, partner evaluation and treatment if sexual contact with the patient within 60 days of symptom onset.  Failure to improve within 3 days requires a re-evaluation of diagnosis and treatment.

2)      Chronic epididymitis

1)      Torsion of testis – surgical emergency

2)      Torsion of appendices of testis – small, painful, tender, firm, para testicular nodule felt at the superior pole of the testis,  managed conservatively with rest, testicular elevation, and NSAIDS

1)      Neonate with an inconsolable crying episode, similar to past recurrent episodes with spontaneous resolution (testicular torsion needs exclusion)

2)      Postpubertal child with acute scrotum, past similar recurrent episodes with spontaneous resolution (needs exclusion of testicular torsion)

3)      Early adolescence with acute scrotum (torsion of appendices of testes and epididymis)

4)      Epididymitis of childhood – exclude sexually transmitted diseases

5)      Acute scrotal pain with absent cremasteric reflex – a pinch or light upstrokes in the superior medial aspect of thighs elicit elevation of the ipsilateral testicle.  This reflex is absent in the  testicular torsion

1)      Severe scrotal pain of sudden onset (testicular torsion, testicular infarction, testicular abscess)

2)      Adolescent with severe scrotal pain (testicular torsion, radionuclide scanning of the scrotum is the most accurate method of diagnosis)

3)      Delayed resolution or non-resolution of acute epididymitis for standard therapy (exclude testicular tumor, abscess formation, testicular infarction, testicular cancer, TB, fungal epididymitis)

4)      Ecchymotic patch in the scrotum – Bryant’s sign – may indicate blood trickled down from the abdominal cavity via a patent process vaginalis in case of abdominal aortic aneurysm, peritonitis, strangulated inguinal hernia

5)      Deep skin cellulitis with necrosis and gangrene (sloughing, foul-smelling dead tissue ) involving the scrotal skin and lower abdominal areas due to a polymicrobial infection (Fournier’s gangrene requires early surgical referral, risk factors for Fournier’s gangrene – type2DM, ethanol abuse, local trauma, perineal instrumentation, paraphimosis, extravasation of urine periurethral or through a cutaneous fistula,  sexually transmitted diseases causing urethral stricture, circumcision, hernioplasty),

6)      Acute scrotal pain with abdominal pain and signs (peritonitis)

7)      Acute scrotal pain with renal colic like the picture in an elderly hypertensive (rupture of abdominal aortic aneurysm)

8)      Scrotal pain and inguinal reducible or irreducible lump (strangulated inguinal hernia)

9)      Fever, chills, lower abdominal pain, scrotal pain, scrotal skin erythema, perineal swelling, crepitus, early ultrasound demonstrate thick scrotal skin, soft tissue gas,

(CDC – Sexually Transmitted Diseases Treatment Guidelines 2006 )

(David, Yale and Goldman 2003)

1)      Hypoglycemic convulsions – SFD, babies of toxemic mothers, twins, babies of diabetic mothers, twitches, cyanotic attacks, convulsions – Mx – pediatric referral

2)      Hypocalcemic convulsions

3)      Septicemia

1)      Breath Holding Attacks – 6/12-5 yrs, provoked cry, breath holding in the expiration, appearing pale or cyanotic before losing consciousness, the child goes limp, generalized convulsion, opisthotonus and incontinence +/- if breath held for more than 15 secs, sequence of symptoms diagnostic,

2)      Benign childhood epilepsy – fits onset 4-12 yrs, simple partial seizures motor type, generalized tonic-clonic seizures, fits in sleep, EEG – centrotemporal sharp waves, fits remission by 14-16 yrs,

3)      Isolated seizures

4)      Idiopathic epilepsy

5)      Idiopathic epilepsy complex partial seizures

6)      Rolandic Seizures

7)      Infantile spasms – fits onset 4-6/12 age, sudden rapid flexion of trunk lasting less than a second, typical fits stop by 18/12 to be replaced by generalized convulsions, characteristic EEG

8)      Generalized absence seizures or Petit mal – onset 4-8 yrs, usually stops by puberty, normal IQ, brief arrest of consciousness lasting less than 20 secs, child may just have a vacant stare, drop things, upward deviation of eyes, arrest of normal activity, episodes of unresponsiveness, episodes of unawareness, no aura, no fits, no postictal events, EEG – ictal/interictal 3 Hz spike-wave complexes

9)      Grand mal – convulsive twitchings, falls, body stiffness, postictal drowsiness,

10)    Benign neonatal familial convulsions – dominant, may be severe and resistant for a few days, febrile or afebrile seizures may occur later, no dysmorphism,

11)    Infantile familial convulsions – dominant, seizures often in clusters (overlap with benign partial complex epilepsy of infancy), no dysmorphism,

12)    Benign myoclonic epilepsy of infancy – often seizures during sleep, no dysmorphism,

13)    Partial idiopathic epilepsy with rolandic spikes – most frequent, partial seizures (sylvian seizures – face, pharynx, respiratory noises), may appear generalized (secondary generalization), seizures mostly  in relation to sleep (falling asleep, early morning, change in sleep habits), EEG – typical focal sharp waves, in the centrotemporal region, but location may vary, multiple independent foci, sometimes only present in sleep EEG, usually more alarming than clinical state, most cases rare seizures, 100% good prognosis, treatment often not necessary, occasionally long and frequent seizures and atypical forms, temporary cognitive behavioral problems in the active phase of the disease only, no dysmorphism,

14)    Idopathi partial occipital epilepsy – early childhood forms with seizures in sleep and ictal vomiting, may present as status epilepticus,  later forms with migrainous symptoms, no dysmorphism,

15)    Petit mal or absence epilepsy – patients with absences only, some have generalized seizures, 60-80% full remission, absences disappear on therapy, no dysmorphism,

16)    Juvenile myoclonic epilepsy – adolescence onset, early morning myoclonic seizures, generalized seizures during sleep, past absences in childhood, no dysmorphism,

1)      Birth asphyxia

2)      Microcephaly

3)      Suture separation (cerebral hemorrhage, subdural effusion)

4)      Bulging fontanelle (cerebral hemorrhage, subdural effusion)

5)      Progressive jaundice

6)      Dehydration

1)      Less than 1 yr

2)      GCS < 15 after 1 hr post fit

3)      Any neurological sign

4)      Papilloedema (RICP)

5)      Tense fontanelle (RICP)

6)      Irritable, disinterested, vomiting (sick child)

7)      Meningism  (Kernig’s positive, photophobia, neck stiffness)

8)      Complex seizure (prolonged > 15 mts), focal, recurrent)

9)      Respiratory distress

10)    High parental anxiety

11)    New onset seizures

12)    First seizure (high possibility of symptomatic etiology )

13)    Mental retardation

14)    Cerebral palsy

15)    Head injury

16)    Rapidly enlarging head circumference

17)    Facial port-wine stain and mental retardation (Sturge Weber syndrome)

18)    Hypoglycemic fits (fits occurring in fasting states – pediatric referral for further evaluation)

19)    Dehydration fits (mainly electrolyte disturbance)

20)    Past meningitis, head injury, subdural effusions (symptomatic epilepsy)

21)    Fever, alteration of consciousness, neurological signs (intracranial infections)