Posted in Patient Information

Penile Adhesions in Male Children

Adapted from: Penile Adhesions Parent Information CHOP Website

What are penile adhesions

Penile adhesions in circumcised boys occur when the penile shaft skin adheres to the glans of the penis. There are three types of penile adhesions: glanular adhesions, penile skin bridges and cicatrix.

Causes

Some adhesions may develop due to an excess of residual foreskin following a newborn circumcision. Adhesions can also form as an infant develops more fat in his pubic area (the area around the penis and scrotum).

Symptoms

The penis may appear that it is “buried” in the prominent pubic fat pad. Because the penis remains hidden there is a tendency for the shaft skin to adhere to the glans.

With all adhesions you may notice a white discharge coming from the area of the adhesions. This is called smegma. Sometimes smegma can be mistaken for a cyst or pus under the skin, but it is not an infection and does not require antibiotics. Smegma consists of dead skin cells that accumulate underneath the adhesions and help to break them apart.

Diagnosis and treatment

Penile adhesions are generally benign and cause no pain or discomfort to your son. You or your pediatrician may notice them during a physical exam.

Treatment is generally performed by a urologist. They will determine by physical exam the type of penile adhesion and what treatment approach is recommended.

Glanular adhesions

On exam you may not be able to see the complete coronal margin. This is the purple line that separates the glans from the shaft of the penis. This is because the shaft skin has adhered to the glans, covering the coronal margin. Glanular adhesions are benign and when left alone tend to resolve on their own. To help the adhesions separate more quickly, we may suggest applying Vaseline® directly to the adhesions. The Vaseline will soften the adhesions, and with spontaneous erections, the adhesions will begin to break apart on their own.

Penile skin bridge

In some instance, the penile shaft skin will become attached to the coronal margin and develop a thicker permanent attachment that cannot be separated and will not separate on its own. You may notice a band of skin from the shaft adhering to the glans with a small tunnel underneath. In many situations the skin bridge can be divided during an outpatient procedure. Treatment may also involve division of the skin bridge and circumcision revision.

Cicatrix

Following a circumcision, the penis may drop back into the pubic fat pad and the surgical area may contract, trapping the penis. In this situation, you will not be able to expose the glans of the penis at all. We have found that cicatrix can be safely and effectively treated with a topical steroid cream. Your child’s doctor will give you instructions on the proper use of the cream. If the steroid cream fails and the penis remains trapped, a circumcision revision and correction of a concealed penis may be necessary.

Posted in Patient Information

Allergy Medication Dosing for Children

Quick reference of allergy med dosing for children.

Zyrtec (cetirizine) dosing:

  • 6-12 months: 2.5 mg once daily
  • 1-2 years: 2.5 mg once to twice daily
  • 2-5 years: 2.5 – 5 mg once daily
  • 6 years and up: 5 – 10mg once daily

Claritin (loratadine) dosing:

  • 2 – 5 years: 5 mg once daily
  • 6 years and up: 5 – 10 mg once daily

Allegra (fexofenadine) dosing:

  • 6 months and < 10.5kg: 15mg twice daily
  • < 2 years or < 10.5kg : 15 – 30 mg twice daily
  • 2 – 11 years: 30 mg twice daily
  • 12 years and up: 180 mg ER once daily

Flonase (fluticasone) dosing:

  • 4 years and up: 1 spray per nostril once daily. If not working, ok to increase to 2 sprays each nostril, but reduce to once daily as soon as possible
  • 12 years and up: 2 sprays each nostril once daily

Reference

Posted in Clinician Information

Tuberculosis Screening and Latent TB Treatment for Primary Care

Screening Recommendations for Tuberculosis in Healthcare Workers

In the May 17, 2019 MMWR, the CDC changed their recommendation on how to screen healthcare workers for TB. Here’s the short version of their recommendations:

  1. TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement);
  2. TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI);
  3. No routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission;
  4. Encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated;
  5. Annual symptom screening for health care personnel with untreated LTBI;
  6. Annual TB education of all health care personnel.

Diagnosing Latent TB

If a person has a positive IGRA or TST, but has no symptoms of disease they meet criteria for Latent TB.

Treatment of Latent TB

Want to keep it simple? Treat latent tuberculosis with 4 months (120 doses) of once daily Rifampin. Dose is weight based. Adults are 10 mg/kg. Children must be age 2 years or older, their dose is 15-20 mg/kg. Rifampin (rifampicin; RIF) is formulated as 150 mg and 300 mg capsules. Max dose is 600 mg.

You can use these logs from the CDC to help the patient track their medications. CDC says that patients should be seen monthly to check for treatment-associated adverse events (systemic drug reactions, loss of appetite, vomiting, yellow eyes, tenderness of the liver, easy bruising, rash). Sounds like a good idea at least to have a telephone call with the patient each month. Don’t panic if the patient reports urine or saliva turning a reddish-orange color – it is not uncommon (although you should make sure that’s the only symptom they are experiencing).

There are great handouts and more information on the CDC website for Latent TB.

Reference:

  1. Health System Costs of Treating Latent Tuberculosis Infection With Four Months of Rifampin Versus Nine Months of Isoniazid in Different Settings, Annals of Internal Medicine
Posted in Fun

Normal Vitals Wall Decor

Have trouble remembering normal vitals for children of various ages? Try decorating with these wall photos and you’ll never forget again!

A day without demographics is like a day without sunshine
A day without demographics is like a day without sunshine
Fever = 100.4 F
Fever = 100.4 F
Minimum wet diapers in 24 hours: 3
Minimum wet diapers in 24 hours: 3
Newborn to 6 months: 120-150 bpm
Newborn to 6 months: 120-150 bpm
6 to 12 months: 110-140 bpm
6 to 12 months: 110-140 bpm
1-2 years: 90-130 bpm
1-2 years: 90-130 bpm
3-5 years: 80-120 bpm
3-5 years: 80-120 bpm
6-12 years: 70-110 bpm
6-12 years: 70-110 bpm
13+: 60-100 bpm
13+: 60-100 bpm
0-12 months: 30-50 breaths per minute
0-12 months: 30-50 breaths per minute
1-2 years: 25-40 breaths per minute
1-2 years: 25-40 breaths per minute
3-5 years: 20-30 breaths per minute
3-5 years: 20-30 breaths per minute
6 to 12 years: 16-25 breaths per minute
6 to 12 years: 16-25 breaths per minute
13 years and older: 12-20 breaths per minute
13 years and older: 12-20 breaths per minute
Posted in Patient Information

Eczema Home Treatment Plan

“The itch that rashes.”

Managing the symptoms at home can seem can seem daunting, but patients can take control of this condition with changes to the daily routine and a stepwise approach when symptoms worsen.

Prevention (do this every day, always):

Apply moisturizer twice a day.

  • Ointment – most effective, greasy, hard to apply. Won’t burn the skin if it is scratched and dry.
  • Creams – next most effective, thick.
  • Lotions – least effective, easiest to apply.

Apply the maintenance steroid cream once a week as a proactive treatment to prevent flares.

Avoid drying the skin when bathing

  • Shorter showers (not baths) are better.
  • Use cooler water, less than 104 °F (40° C).
  • Use a simple bar soap like a Dove bar. Fancy soaps have fancy chemicals.
  • Soap the Face, Armpits, Groin, Feet, Hands. Other areas do not need soap unless they are soiled or very dirty.

Minor flare – use your steroid every day!

  • Apply your regular steroid to all affected areas twice a day, Monday through Friday. Take a break on the weekend to ensure the steroid continues to be effective.
  • Continue to use moisturizers and avoiding long hot baths.

Severe flare – time for a stronger steroid!

  • Apply stronger steroid twice a day, again Monday through Friday.
  • As always, keep using the moisturizer, and maintain your normal skin therapies.
  • When symptoms improve you should work your way back to Prevention in steps. First treat as a Minor flare and only reduce your use of regular steroid when your symptoms are back under control.

Links

Topical Steroid Potency Chart: National Psoriasis Foundation

Posted in Patient Information

Benign Paroxysmal Positional Vertigo (BPPV) Treatment

RIGHT: Epley maneuver for self-treatment of benign positional vertigo

Treatment of Right Sided BPPV (Epley maneuver)
  1. Lie back quickly with shoulders on the pillow and head reclined onto the bed. Wait for 30 seconds.
  2. Turn your head 90° to the left (without raising it) and wait again for 30 seconds.
  3. Turn your body and head another 90° to the left and wait for another 30 seconds.
  4. Sit up on the left side.
  5. Start sitting on a bed and turn your head 45° to the right. Place a pillow behind you so that on lying back it will be under your shoulders.

LEFT: Epley maneuver for self-treatment of benign positional vertigo

Treatment of Left Sided BPPV (Epley maneuver)
  1. Start sitting on a bed and turn your head 45° to the left. Place a pillow behind you so that on lying back it will be under your shoulders.
  2. Lie back quickly with shoulders on the pillow and head reclined onto the bed. Wait for 30 seconds.
  3. Turn your head 90° to the right (without raising it) and wait again for 30 seconds.
  4. Turn your body and head another 90° to the right and wait for another 30 seconds.
  5. Sit up on the right side.

Post treatment care

This maneuver should be carried out three times a day. Repeat this daily until you are free from positional vertigo for 24 hours.

Wait for 10 minutes after the maneuver is performed doing activities. This is to avoid “quick spins,” or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don’t drive immediately after performing the procedure.

Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary (Cohen, 2004; Massoud and Ireland, 1996). We, as do others, think that there is some value (Cakir et al, 2006)

Sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch.

For at least one week, avoid provoking head positions that might bring BPPV on again.

  • Use two pillows when you sleep.
  • Avoid sleeping on the “bad” side.
  • Don’t turn your head far up or far down.
  • Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist’s office, and while undergoing minor surgery.
  • Try to stay as upright as possible.
  • Exercises for low-back pain should be stopped for a week.
  • No “sit-ups” should be done for at least one week and no “crawl” swimming. (Breast stroke is OK.)
  • Also avoid far head- forward positions such as might occur in certain exercises (i.e. touching the toes).
  • Wait to start doing BPPV exercises (Brandt-Daroff) for 2 days following the Epley or Semont maneuver, unless specifically instructed otherwise by your doctor.

At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can’t fall or hurt yourself. Let your doctor know how you did.

Links

Dr. Hain’s BPPV Info
Vestibular Disorders Association
Geriatric Depression Scale
Berg Balance Scale (PDF)
Dizziness Handicap Inventory (PDF)

Posted in Inpatient

COVID-19 Respiratory Failure Treatment

For inpatient treatment of COVID-19 pneumonia with acute respiratory failure (aka, people with a positive COVID-19 test who need oxygen to keep their SPO2 > 92%).

Oxygen therapy levels

  1. Titrate oxygen for SPO2 > 92%
  2. Oxygen delivery modalities, stepwise:

↑↑↑ Less oxygen delivered ↑↑↑

  • Simple face-mask (avoid)
  • Non-Rebreather (face-mask with bag, also avoid)
  • Nasal cannula
  • Venturi Mask / Oxymask
  • High-Flow Nasal Cannula
  • BiPAP
  • Intubation & Ventilator

↓↓↓ More oxygen delivered ↓↓↓

Non-medication adjuncts

  1. Incentive spirometry (IS) at bedside (how to use IS)
  2. Encourage patients to “self-prone” by changing position every 30 minutes, choosing between sitting up, left side, back, right side, stomach.  (Note: Qian et. al 2022 [PDF]suggests that self-proning in non-intubated patients may not confer benefit.)

For all patients requiring oxygen (respiratory failure)

  1. Dexamethasone 6 mg IV or PO q24 hours for 10 days
  2. Remdesivir 200 mg IV x 1, then 100mg IV q24 hours for 5 days, or

For high risk patients, or anybody that acutely worsens

It is not yet clear whether baricitinib or tocilizumab is superior. Choice depends mostly on availability and institutional practice.

  1. An anti-inflammatory medication, either:
  • Baricitinib 4 mg PO for 14 days, or
  • Tocilizumab 8mg/kg (weight >= 30kg) or 12mg/kg (weight < 30kg) IV infusion x 1 (max dose 800 mg)

If bacterial pneumonia suspected

2-3% of COVID-19 pneumonia patients also develop bacterial pneumonia.

  1. Ceftriaxone 2 gm IV q24 hours x 5 days,
  2. Plus pick one:
  • Usually: Azithromycin 500 mg IV q24 hours x 5 days, or
  • If concern for MRSA: Doxycycline 200 mg IV x 1, then 100 mg IV q12 hours for 10 days

For symptom relief

  1. Tessalon perles (aka benzonatate) PRN cough
  2. Guaifenesin (with or without codeine) PRN cough
  3. Ipratropium-albuterol nebulizer treatments PRN shortness of breath
  4. Acetaminophen PRN pain/fever/headache

DVT prophylaxis

  1. Pick your favorite prophylaxis:
  • Lovenox 30-40 mg SQ q24 hours (normal prophylactic dose, adjusted for renal function if necessary), or
  • If kidney injury: Heparin 10K units q8-12 hours

NIH COVID-19 Hospitalized Patient Management

Feature Image attribution: CDC PHIL #23354, downloaded on 3/14/2022

Posted in Procedures

Lipoma Removal

Equipment List

  1. Sterile gloves (1 pair)
  2. 15 Blade Disposable Scalpel (1)
  3. Iris Scissors, Straight (1 pair)
  4. Needle Driver (1 pair)
  5. Toothed Pickup (1)
  6. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1)
    • 4-0 Ethilon (1)
  7. 10 ml syringe (1)
  8. 18 gauge 1.5 inch needle (1)
  9. 27 gauge 1.25 inch needle (1)
  10. ChloraPrep 3mL stick (1)
  11. Alcohol Swabs (4)
  12. Sterile 4×4 gauze (5)
  13. Sterile 2×2 gauze (2)
  14. Paper Medical Tape (1 roll)
  15. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  16. Chux Pads (1)
  17. Formalin cups (as many cups as specimens)
  18. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)

Procedure Note

LIPOMA REMOVAL

The procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion, and infiltrated with _ mL of _% lidocaine with_ epinephrine for local anesthesia. The lipoma was palpated superficially under the dermis. An incision was made directly over the lipoma, and gentle blunt dissection was performed to free and then remove the lipoma. The specimen was placed in specimen jar and sent for analysis. Closure was performed with _ simple interrupted sutures using _ type of suture. Petroleum ointment and a bandage were applied. EBL was less than 1 ml. Good hemostasis. There were no complications. Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in _ days.

Posted in Procedures

Skin Biopsy

Equipment List

  1. Nitrile Exam Gloves (1 pair)
  2. Sterile Gloves (1 pair)
  3. 15 Blade Disposable Scalpel (1)
  4. Iris Scissors, Straight (1 pair)
  5. Needle Driver (1 pair)
  6. Toothed Pickup (1)
  7. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1) – absorbable for deep or layered repair
    • 4-0 Ethilon (1) – for skin closure
  8. Sterile Medium Drape (1)
  9. ChloraPrep 3 mL stick (1)
  10. Alcohol Swabs (4)
  11. Sterile 4×4 gauze (5)
  12. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)
  13. 10 ml syringe (1)
  14. 18 gauge 1.5 inch needle (1)
  15. 27 gauge 1.25 inch needle (1)
  16. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  17. Chux Pads (1)
  18. Formalin cups (as many cups as biopsy specimens)
  19. Paper Medical Tape (1 roll)
  20. Sterile 2×2 gauze (5)

Procedure Note

EXCISIONAL/INCISIONAL BIOPSY

The procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion, and infiltrated with _ ml of _% lidocaine with_ epinephrine for local anesthesia. An elliptical cision was performed to remove the lesion, and the specimen was placed in specimen jar and sent for analysis. Closure was performed with _ suture material. Petroleum ointment and a bandage applied. EBL less than 1 ml. Good hemostasis. There were no complications. Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in _ days.

Suture Removal Time Period

Face: 5-7 days

Neck: 7 days

Scalp: 10 days

Trunk & Upper Extremities: 10-14 days

Lower Extremities: 14-21 days

Sutures in wounds under greater tension may have to be left in place slightly longer.