Genital herpes
2007-11-08 11:36:16
Genital HSV infection is usually transmitted through sexual contact. About 21.9 percent of all persons in the United States 12 years of age or older have serologic evidence of HSV-2 infection. Risk factors include multiple sexual partners, increasing age, female gender, low socioeconomic status and human immunodeficiency virus (HIV) infection.
Clinical presentation
Primary genital herpes has an incubation period of two to 12 days, with a mean of four days, followed by a prodrome of itching, burning or erythema. Multiple transient, painful vesicles then appear on the penis, perineum, vulva, vagina or cervix, and tender inguinal lymphadenopathy may follow. The initial ulceration crusts and heals by 14 to 21 days. Systemic symptoms include fever, headache, malaise, abdominal pain and myalgia. Recurrences are usually less severe and shorter in duration than the initial outbreak.
Approximately 90 percent of those infected are unaware that they have herpes infection and may unknowingly shed
Herpes Simplex Virus Infections
2007-11-08 11:28:16
Herpes simplex virus (HSV) affects more than one-third of the world’s population. HSV exists as types 1 and 2, which have affinities for different body sites. Ninety percent of infections caused by HSV-2 are genital, and 90 percent of those caused by HSV-1 are oral.
Diagnosis
The diagnosis of genital HSV infection may be made clinically, but laboratory confirmation is recommended in patients presenting with primary or suspected recurrent infection. The gold standard of diagnosis is viral isolation by tissue culture, although this process can take as long as four to five days, and the sensitivity rate is only 70 to 80 percent. Viral culture is still the diagnostic test of choice for HSV skin infections.
Polymerase chain reaction enzyme-linked immunosorbent assay (PCR-ELISA) is extremely sensitive (96 percent) and specific (99 percent) but expensive. For this reason, it is not used for the diagnosis of skin lesions but is the test of choice for diagnosing HSV encephalitis.
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New Treatments for Sleep Disorders 2
2007-11-16 04:07:54
Now the other leg of the interpretation is SOREMP, sleep onset REM period. That’s abnormal. Unless you are in your first year of life. The reason we do this is because two SOREMP’s - that means if it happens twice or more out of your four or five nights of MSLT - it is said to be highly specific and suggestive of narcolepsy. You as a neurologist, and a taker of neurology Boards, needs to know that. It is totally specific? Of course not. You know by now that you will never say something is 100% specific and 100% sensitive. They don’t have to tell you that. But it’s pretty good, 80%, 70%, whatever. The point is, if you get severely sleep deprived - you stay up all night because you are on call - you do a MSLT tomorrow, you may have sleep onset REM period. Again, it has to be interpreted in the context of the previous night, which is measured objectively by a polysomnogram. So severe obstructive sleep apnea, severe sleep deprivation, will cause sleep onset REM period.
Finally, I
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New Treatments for Sleep Disorders
2007-11-16 04:01:16
Clinically, these are the three studies that we do. This is all you need to know about. The current thinking is that the majority of impotence is not psychogenic, so this is an important thing to do when people are making a diagnosis of psychogenic impotence. Now let’s talk about the other two, which you are more likely to be asked about I think. Polysomnogram occurs all night, records sleep architecture and makes the diagnosis of the major sleep disorders, intrinsic sleep disorders, which are sleep apnea and nocturnal myoclonus. Narcolepsy is a major sleep disorder but the polysomnogram is usually normal during narcolepsy. First night effect: when we put somebody in the lab with leads all over the place and sometimes in unpleasant places, they don’t sleep very well. So there is an artifact finding in every sleep study, which is: it is not a typical night’s sleep. We know that. How do we measure it? It’s called the first night effect. What happens if tomorrow you go to sleep in
Read more: Sleep
Sleep Disorders
2007-11-15 03:54:38
Functions of sleep? The easy answer is we don’t know. We do know, like with most physiologic functions, how do we know what it does? We take it away and see what happens. When you take sleep away experimentally you do have impaired performance and you do have sleep cravings. If you stop sleep, you will crave it more and more, just like hunger. And eventually you will sleep. You are more likely to fall asleep in an inappropriate setting, as we will discuss. Selective REM deprivation, the classic question and the old teaching was if you deprive somebody of REM sleep selectively you cause psychosis. That is not true. No, no, no. This is an artifact of a poorly-done study in the 1950’s. Not true. The same thing you get with non-REM sleep you get REM fresher, you get REM rebound, you get more and more craving of REM sleep and eventually, whether you like it or not, you go in REM sleep. That’s what people with narcolepsy do.
Sleep
studies. Let me give you what you need to know about th
Therapy for GERD
2007-11-14 11:49:02
1 ) Non-medical Therapy
The so-called lifestyle modifications to treat GERD are generally successful only in patients with minimal reflux disease and include elevation of the head of the bed by 4 to 6 inches, avoiding eating meals within 3 hours of recumbency, avoiding cigarettes and alcohol, avoiding chocolate, fatty foods and carminatives; and avoiding NSAIDS.
2) H2 Antagonists
For patients who fail lifestyle modifications, the classic drugs most commonly used to treat GE reflux disease are the H2 antagonists. In people with symptoms of mild reflux, these agents are often successful. However, in patients with erosive esophagitis healing is only seen in approximately 58%. As a general rule, therefore, patients with severely symptomatic heartburn, particularly associated with reflux disease, more potent agents are generally needed.
3) Prokinetic Agents
It is attractive to treat GE reflux disease by preventing the actual occurrence of reflux rather than neutralizing gastric contents. Pr
“Cardiac” Complications
2007-11-14 11:45:00
Angina-like non-cardiac chest pain of esophageal origin was proposed by Hippocrates. For many years the concept of &ldquo
;esophageal spasm&rdquo
; has held its place in the medical literature although documenting consistent esophageal motility disorders in these patients has been difficult. Recent work by Richter et al has demonstrated that up to 50% of patients with anginal-like chest pain and negative cardiac catheterizations in fact have GE reflux disease, and certainly a trial of proton pump inhibitor therapy is warranted in patients with anginal-like pain and negative cardiac workups.
Extra-esophageal Manifestations
2007-11-14 08:00:34
The extra-esophageal manifestations of GE reflux disease are now being more frequently recognized and treated. These manifestations include ENT manifestations including reflux laryngitis, laryngeal stenosis, laryngeal carcinoma, chronic hoarseness, chronic cough and globus sensation.
Pulmonary manifestations include asthma, chronic cough, aspiration pneumonia and pulmonary fibrosis.
The association between GE reflux disease and chronic pulmonary disease has been speculated upon for many years. The pathophysiology for this connection remains poorly understood and is complicated by the fact that many of the treatments for patients with chronic lung disease and the lung disease itself can exacerbate GE reflux disease.
The two most commonly proposed theories include a neural reflex caused by acid reflux into the distal esophagus versus micro-aspiration of tiny amounts of acid into the tracheobronchial tree with resultant bronchospasm and/or pulmonary parenchymal damage. At present, there i
Read more: Extra
Complications of GE Reflux Disease
2007-11-13 20:11:15
As commonly used, Barrett’s esophagus now refers to the presence of specialized intestinal metaplasia in the distal esophagus. It is only when intestinal type mucosa associated with goblet cells is seen that we use the term Barrett’s esophagus. There has been an enormous surge in interest in Barrett’s esophagus due to the marked increase in incidence in adenocarcinoma of the GE junction of which Barrett’s esophagus is felt to be the predisposing condition. The risk of developing esophageal carcinoma in a patient with Barrett’s esophagus remains a subject of great controversy. Depending on the series, the prevalence of carcinoma has ranged between 4% and 45%. Recent studies demonstrate that carcinoma will develop in patients with established Barrett’s esophagus in one patient out of 80 to one patient out of 450 per year. Therefore, although the risk of esophageal adenocarcinoma is about 35 times that of the general population in patients with Barrett&
Read more: Reflux
GERD. Complications of GE Reflux Disease
2007-11-12 21:51:02
Complications of GE Reflux
Disease
Sequelae of GERD are typically broken down into the esophageal complications and the extra-esophageal manifestations.
-Esophageal Complications:
—Peptic Strictures: These can develop in patients with symptomatic heartburn or in patients with clinically silent heartburn. They generally present as solid food dysphagia unattended by weight loss. These are generally treated with anti-reflux medications and with endoscopically guided dilation.
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-Barrett’s Esophagus: With the advent of high resolution video endoscopy Barrett’s esophagus, particularly short segment Barrett’s esophagus (less than 3 cm in length) is being seen in up to 10-15% of patients having endoscopy for GE reflux. Of interest, many of the patients with Barrett’s esophagus do not have symptoms of severe heartburn and do not therefore seek medical attention. This may be because the Barrett’s mucosa is protective and prevents es
GERD. Diagnostic Studies in GE Reflux Disease
2007-11-12 11:22:40
A number of studies are used to evaluate people who have suspected GE reflux disease. Barium esophagram is the study that was traditionally used to evaluate GE reflux disease. It is easy and inexpensive to perform and when gross reflux is demonstrated is 85% specific. The shortcoming of this study lies in its sensitivity rate of 40%. Upper endoscopy is now the most frequently used study to evaluate suspected GE reflux disease. Indeed, when erosive esophagitis is identified by the endoscopist, specificity is in the 95% range. Many patients, however, who have GE reflux disease have no evident mucosal injury so the sensitivity of the study is in the 50-60% range.
The study that is now becoming accepted as the gold standard is the 24 hour ambulatory esophageal pH monitor. This study is performed by placing a pH probe with its tip 5 cm above the lower esophageal sphincter. The device is connected to a small monitor which is carried by the patient and records the pH during the course of the
Read more: Reflux
, Studies
GERD. Pathophysiology
2007-11-11 19:17:58
Pathophysiology
The development of GE reflux disease depends on a combination of the following four factors: (1) defective anti-reflux mechanism, (2) the presence of caustic gastric contents, (3) poor esophageal clearance, (4) diminished esophageal mucosal resistance.
1) Anti-reflux mechanism
As intra-abdominal pressure is always greater than intrathoracic pressure, if it were not for an anti-reflux barrier, GE reflux would be occurring almost constantly. The role of the esophageal sphincter refers to a segment of specialized circular mucosa at the GE junction approximately 3 cm in length which maintains a pressure 10 mmHg to 40 mmHg higher than the pressure of the stomach thereby preventing GE reflux.
Before the advent of widespread use of esophageal manometry, primary LES hypotonia was felt to account for all cases of GE reflux disease. Using modern manometric techniques, however, it has been demonstrated that only the minority (10-20%) of patients with GE reflux disease do in fact h
Headaches Caused by Serious Underlying Disease
2007-11-22 12:05:29
Headaches Caused by Serious Underlying Disease
Fewer than 1% of headaches are caused by serious underlying disease. A neuroimaging study is warranted when the history or physical suggest an underlying disease.
Potential Causes of Headache
Subarachnoid Hemorrhage. A headache occurs in 50% of patients with subarachnoid hemorrhage, often described as the worst headache they have ever had. The headache is very localized, and meningismus, paresis of the third, fourth, or sixth cranial nerve, nausea, vomiting, altered mentation, and loss of consciousness may occur. A CT scan is essential when subarachnoid hemorrhage is suspected.
Giant Cell Arteritis
Giant cell arteritis is an autoimmune-type process, most commonly affecting the temporal artery. The inflammation may cause headache, infarction of the optic nerve, and blindness.
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It almost always occurs after age 50 and is 5 to 10 times more prevalent in women. Tenderness of the temporal artery, jaw claudication, sudd
Headache
2007-11-22 11:38:04
Migraine affects 15% to 17% of women and 6% of men. During migraine attacks, the “migraine generator” of the brain stem site becomes activated, then the trigeminal nerve, which innervates the larger cerebral vessels, releases serotonin and vasoactive peptides. These substances cause inflammation of the dura mater and cranial blood vessels, resulting in the symptoms of migraine.
Common Benign Headache
Syndromes
Migraine
Migraine headache is often associated with nausea, vomiting, diarrhea, fatigue, and mood changes. A prodrome that begins up to 24 hours before headache onset may also occur. Photophobia, phonophobia, food cravings, mood changes, myalgia, and paresthesia may also be observed.
Migraine without aura occurs in two-thirds of patients, manifesting as attacks that last 4 to 72 hours. The attacks may recur daily, weekly, or monthly. The headache is unilateral, pulsating, of moderate or severe intensity, and aggravated by physical activity. Nausea and/or vomiting,
Bipolar Disorder. Treatment
2007-11-20 07:53:25
Lithium carbonate remains the mainstay of treatment in bipolar disorder, although sodium valproate is equally effective in acute mania. Carbamazepine is also efficacious. The response rate to lithium carbonate is 70 to 80 percent in acute mania, with beneficial effects appearing in 1 to 2 weeks. A prophylactic effect in prevention of recurrent mania, and, to a lesser extent, in the prevention of recurrent depression is documented. A simple cation, lithium is rapidly absorbed from the gastrointestinal tract and remains unbound to plasma or tissue proteins. Ninety-five percent of a given dose is excreted unchanged through the kidneys within 24 h.
Serious side effects from lithium administration are rare, but minor complaints such as gastrointestinal discomfort, nausea, diarrhea, polyuria, weight gain, skin eruptions, alopecia, and edema are common. Over time, urine concentrating ability may be decreased, but changes in function do not result in significant nephrotoxicity. In a small subs
Read more: Bipolar
, Treatment
Differential Diagnosis
2007-11-20 07:38:45
Differential Diagnosis The differential diagnosis of mania includes ruling out activation by stimulant and sympathomimetic compounds as well as secondary mania induced by hyperthyroidism, AIDS, or neurologic disorders, such as Huntington’s or Wilson’s disease, or cerebrovascular accidents. This distinction may be difficult to make, because comorbidity with alcohol and substance abuse is common, either because of poor judgment and increased impulsivity or because of an attempt at self-medication.
Etiology And Pathophysiology Evidence for a genetic predisposition to bipolar disorder is significant. The concordance rate for monozygotic twin pairs approaches 80 percent, and segregation analyses are consistent with autosomal dominant transmission. Several chromosomal locations for the gene have been proposed in the last decade on the basis of linkage analysis in affected families. None has yet received independent confirmation. Two independent groups reported the results of comp
Bipolar Disorder
2007-11-20 07:35:59
Bipolar disorder affects approximately 3 million persons in the United States. It is characterized by unpredictable swings in mood from mania (or hypomania) to depression. Some patients suffer only from recurrent attacks of mania, which in its pure form is associated with increased psychomotor activity, excessive social extroversion, decreased need for sleep, impulsivity and impairment in judgment, and expansive, grandiose, and sometimes irritable mood. In severe mania, patients may experience delusions and paranoid thinking indistinguishable from that associated with schizophrenia. About half of all patients with bipolar disorder present with a mixture of psychomotor agitation and activation with dysphoria, anxiety, and irritability. It may be difficult to distinguish mixed mania from agitated depression. In some bipolar patients (bipolar II disorder), the full criteria for mania are lacking, and recurrent depressions are separated by periods of mild activation and increased energy (h
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Physical therapy modalities
2007-11-26 09:31:02
Rest. Two to three days of bed rest in a supine position may be recommended for patients with acute radiculopathy. Sitting raises intradiscal pressures and can theoretically worsen disc herniation and pain. Activity modification is recommended for patients with nonneurogenic pain. With activity restriction, the patient avoids painful arcs of motion and tasks that exacerbate the back pain.
Physical therapy
modalities
Superficial heat, ultrasound (deep heat), cold packs and massage are useful for relieving symptoms in the acute phase after the onset of low back pain. These modalities provide analgesia and muscle relaxation. However, their use should be limited to the first two to four weeks after the injury.
No convincing evidence has demonstrated the long-term effectiveness of lumbar traction and transcutaneous electrical stimulation in relieving symptoms or improving functional outcome.
Corsets (lumbosacral orthoses, braces, back supports and abdominal binders) for a short period (a fe
Pharmacologic Therapy
2007-11-26 09:29:01
The mainstay of pharmacologic therapy for acute low back pain is acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). If no medical contraindications are present, a two- to four-week course of medication at anti-inflammatory levels is suggested.
Naproxen ( Naprosyn) 500 mg followed by 250 mg PO tid-qid prn [250, 375,500 mg].
Naproxen sodium ( Aleve) 200 mg PO tid prn.
Napro xen sodium (Ana prox) 550 mg, followed by 275 mg PO tid-qid prn.
Ibupro fen (Motr in, Advil) 800 mg, then 400 mg PO q4-6h prn.
Diclofenac ( Voltaren) 50 mg bid-tid or 75 mg bid.
Adequate gastrointestinal prophylaxis, using a histamine H2 antagonist or misoprostol (Cytotec), should be prescribed for patients who are at risk for peptic ulcer disease.
Rofecoxib (Vioxx) and celecoxib (Celebrex) are NSAIDs with selective cyclo-oxygenase-2 inhibition. These agents have fewer gastrointestinal side effects.
Celecoxib ( Celebrex) is given as 200 mg qd or 100 mg bid.
Rofecoxib ( Vioxx) is given as 25-50 mg qd.
For
Read more: Therapy
Laboratory tests
2007-11-26 09:25:14
Laboratory tests
Evaluation may include a complete blood count, determination of erythrocyte sedimentation rate.
Radiographic evaluation. Plain-film radiography is rarely useful in the initial evaluation of patients with acute-onset low back pain. Plain-film radiographs are normal or demonstrate changes of equivocal clinical significance in more than 75 percent of patients with low back pain. Views of the spine uncover useful information in fewer than 3 percent of patients. Anteroposterior and lateral radiographs should be considered in patients who have a history of trauma, neurologic deficits, or systemic symptoms.
Magnetic resonance imaging and computed tomographic scanning
Magnetic resonance imaging (MRI) and computed tomographic (CT) scanning often demonstrate abnormalities in “normal” asymptomatic people. Thus, positive findings in patients with back pain are frequently of questionable clinical significance.
MRI uses no ionizing radiation and is better at imaging soft
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Indications for Radiographs in the Patient with Acute Low Back Pain
2007-11-26 09:21:53
History of significant trauma Neurologic deficits Systemic symptoms Temperature greater than 38EC (100.4EF) Unexplained weight loss Medical history
Cancer Corticosteroid use Drug or alcohol abuse
Ankylosing spondylitis suspected
Waddell Signs: Nonorganic Signs Indicating the Presence of a Functional Component of Back Pain
Superficial, nonanatomic tenderness Pain with simulated testing (eg, axial loading or pelvic rotation) Inconsistent responses with distraction (eg, straight leg raises while the patient is sitting)
Nonorganic regional disturbances (eg, nondermatomal sensory loss) Overreaction
Location of Pain and Motor Deficits in Association with Nerve Root Involvement
Cauda equina syndrome. Physical and neurologic examination of the lumbar spine
2007-11-26 09:12:57
Cauda equina syndrome. Only the relatively uncommon central disc herniation provokes low back pain and saddle pain in the S1 and S2 distributions. A central herniated disc may also compress nerve roots of the cauda equina, resulting in difficult urination, incontinence or impotence. If bowel or bladder dysfunction is present, immediate referral to a specialist is required for emergency surgery to prevent permanent loss of function.
Physical and neurologic examination of the lumbar spine
External manifestations of pain, including an abnormal stance, should be noted. The patient’s posture and gait should be examined for sciatic list, which is indicative of disc herniation. The spinous processes and interspinous ligaments should be palpated for tenderness.
Range of motion should be evaluated. Pain during lumbar flexion suggests discogenic pain, while pain on lumbar extension suggests facet disease. Ligamentous or muscular strain can cause pain when the patient bends contralaterally.
Low Back Pain
2007-11-26 08:56:10
Approximately 90 percent of adults experience back pain at some time in life, and 50 percent of persons in the working population have back pain every year.
Evaluation of low back pain
A comprehensive history and physical examination can identify the small percentage of patients with serious conditions such as infection, malignancy, rheumatologic diseases and neurologic disorders. The possibility of referred pain from other organ systems should also be considered.
The history and review of systems include patient age, constitutional symptoms and the presence of night pain, bone pain or morning stiffness. The patient should be asked about the occurrence of visceral pain, claudication, numbness, weakness, radiating pain, and bowel and bladder dysfunction.
Specific characteristics and severity of the pain, a history of trauma, previous therapy and its efficacy, and the functional impact of the pain on the patient’s work and activities of daily living should be assessed.
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Treatment of Migraine
2007-11-26 08:41:26
Nonpharmacologic therapy includes identification and avoidance of triggers for headaches, adequate sleep, and regular aerobic exercise. Biofeedback and stress reduction techniques may also be useful.
Triggers or Risk Factors for Migraine
Pharmacologic therapy for migraine is divided into acute and preventive therapies. Acute therapy is initiated at the onset of or during an attack to relieve headache pain. Preventive therapy consists of the daily use of a medication to reduce the frequency of attacks. Such therapy should be considered when attacks occur more frequently than two times per month or when attacks are severe.
Acute therapies for migraine
Acute Therapy
5-HT (Serotonin) Agonists
These agents have high affinity and selectivity for 5-HT1B/1D-receptor subtypes, which are located on intracranial vessels.
Sumatriptan (Order Imitrex Online). The oral preparation causes fewer side effects than the subcutaneous preparation. Side effects include sedation, chest pressure, heaviness, ti
Read more: Treatment
Homeopathy. Hypnotherapy. Therapies for Depression
2007-12-04 12:57:21
HOMEOPATHY
Homeopathy is based on the “like cures like” principle that suggests that a remedy (often, but not always, plant based), which causes certain symptoms in a healthy individual, can be used as a treatment for patients presenting with such symptoms. Furthermore, homeopaths believe that, by “potentizing” (stepwise dilutions combined with vigorous shaking) a remedy, it will get not less, but more, potent. They assume that even dilutions devoid of molecules of the original remedy will have powerful clinical effects. (62) Homeopathy is practiced by both physicians and NMQTs. A first consultation will usually last in excess of 1 hour.
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There is a dearth of investigations into homeopathy for depression. The literature consists mainly of unsubstantiated treatment suggestions or case reports. (63, 64) The thorough review by Kleijnen et al (65) and a recent meta-analysis by Linde et al (66) of clinical trials of homeopathy detected only 1
Exercise. Aromatherapy. Therapies for Depression
2007-12-04 12:44:26
EXERCISE
Many categories of physical exercise exist, eg, leisure-time and work-related physical activity or single bout and regular exercise. Their physiological responses may differ considerably. For the purpose of the following discussion, it is helpful to distinguish between regular endurance (mostly aerobic) exercise and power (mostly anaerobic) exercise. For the treatment of depression, exercise can be carried out either under supervision (eg, by a physiotherapist) or independently at home. In practice, a combined approach is usually the best.
A large body of evidence (39) (>1000 trials) exists relating to exercise and depression and numerous reviews (40-53) on the topic have recently been published. A meta-analysis of 80 studies (50) (regardless of their methodological quality) produced an overall mean exercise effect size of -0.53 (range, -3.88 to 2.05). This suggests that the depression scores decreased by approximately one half of an SD more in the exercise groups than in the
Read more: Exercise
, Aromatherapy
ACUPUNCTURE. Depression
2007-12-04 12:37:36
Acupuncture is an ancient Chinese treatment. Based on the belief that 2 types of “energies” flow in “meridians” throughout the body and that an imbalance of these energies constitutes illness, acupuncturists insert needles into points located on meridians with the aim of correcting the imbalance and restoring health. Western acupuncturists are critical of these Taoist theories and attribute acupuncture’s alleged benefits to neurophysiological effects. (22) Hence, the putative mechanism for acupuncture in depression is provided through studies (23) showing that the level of endorphins can be increased through needling. Acupuncture is normally carried out in specialized clinics either by physicians or (more often) by nonmedically qualified therapists (NMQTs). One session would typically last for 20 minutes, and a series of 6 to 12 treatments may be required.
Case series (24,25)indicate that acupuncture is promising for treating depression. Several uncontroll
Complementary Therapies for Depression
2007-12-04 12:29:27
Depression has a prevalence of 5% in the general population. It is estimated that at least one third of all individuals are likely to experience an episode of depression during their lifetime. Complementary
and alternative medicine (CAM) is often negatively defined, for example, as “a system of health care which lies for the most part outside the mainstream of conventional medicine.” (7) A more inclusive definition has been adopted by the Cochrane Collaboration: “complementary medicine is diagnosis, treatment, and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy, or by diversifying the conceptual frameworks of medicine.”
Complementary and alternative therapies (CATs) are popular. In 1991, 34% of the US adult population used at least 1 such therapy for 1 year. This figure has now risen to 40%. (10) Twenty percent of those suffering from depression had used an unconventional therapy
Growth Disorders. When you do the physical exam
2007-12-11 12:43:41
When you do the physical
exam on these children it’s normal. If the child is typically around the age that puberty would be expected to start, it usually hasn’t. If you do the bone age - typically I would - you would find it to be delayed. Also remember, very importantly, the timing of puberty correlates more closely with the bone age than the chronological age if the two are discordant. And that can be in either direction. If you look at the family history of children with constitutional delay, usually about half the time one or the other parent has a similar story. Ask the mother when she had her menarche, ask the father if he grew after age 18. That’s typically things they can remember. As to the outcome of these children, the final height is typically at or within the target range. The pubertal growth spurt sometimes is blunted and expect it to be delayed relative to the peers. Thus, because it might be slightly blunted, these children may not quite get to their genetic targe
Read more: Growth
This is one of about ten growth charts
2007-12-11 12:41:31
This is one of about ten growth charts that are in your packet sort of as an appendix. What is shown here is a growth chart showing heights of a female child between the ages of about 3 all the way up to about 18, and I’ll sort of say it in words. You can see the heights are below the 5th percentile but parallel to it. Out here in this bracketed area is the mid-parental target height, so this child ended up right in the middle of where she was supposed to. The arrows represent the fact that this was when menarche occurred, which was about age 13 which is normal, and also that a physician did a bone age x-ray at this period in time, which was equal to the chronological age. This growth pattern is classical for familial short-stature. Characteristics in words of this entity, which is a mere normal variation, are that the annual growth rate is normal, the height is at or below the third percentile - so the children are short but grow at a normal clip - there is no systemic or endocrine
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