Clinical questions - Pediatrics Flashcards
12 mo old developmental milestones
rule of 2s
- 2 legs - stand, walk
- 2 words
- 2 blocks
- 2 fingers - pincer grasp
Suspected child abuse
call CPS
evaluate for other injuries - new or old
PT/PTT, CBC, metabolic panel to r/o thrombocytopenia or coagulapathy contributing to bruising
skeletal survey
CT head if indicated, especially + retinal hemorrhage
APGAR scoring
Appearance: blue 0 acrocyanosis 1 pink 2
Pulse: absent 0 less than 100 1 >100 2
Grimace: absent 0 grimace or feeble cry 1 strong cry 2
Activity: no tone 0 some flexion 1 flexed arms and legs 2
Respiration: absent 0 weak/irreg 1 reg, strong cry 2
Respiratory distress syndrome
nasal flaring and grunting, rapid RR, CXR with hazy interstitial infiltrates
prematurity
Tx:
resp support:
-CPAP if FiO2 less than 0.4, wean off as able
-Intubate and exogenous surfactant if FiO2 > 0.4
Prevent: prior to delivery, IM betamethasone or corticosteroids to mom
Metabolic abnormalities associated with pyloric stenosis or other frequent emesis
hypochloremic, hypokalemic metabolic alkalosis
HCl lost in vomit
Loss of H+ causes alkalosis
H-K pump shuttles K intracellularly to pump H out to compensate for alkalosis
Pneumatosis intestinalis
hallmark of necrotizing enterocolitis
premature with bilious vomiting and lethargy
Abd XR with air in the wall of the intestines
Tx: Stablize pt stope enteral feeds start parenteral feeds Antibiotics - amp + cefotaxime + metronidazole If perf -> surgery
Croup
bark like cough, worse at night
Tx:
supportive care
O2 only if hypoxic
single dose of dexamethasone with prn follow up
If stridor or worse looking
- > hospitalize
- > Racemic epi nebulizer
causes and treatment for neonate fever with seizure
MC: GBS, e.coli
LC: listeria, enterococcus, staph, GN, HSV
Abx:
Amp + cefotaxime OR amp + gent
If seizure, ill appearing, has vesicles or CSF pleocytosis add on acyclovir to cover HSV encephalitis
Fever of unknown origin
If ill appearing and leukocytosis get a CXR even if no respiratory symptoms
If ill -> hospitalize
If outpatient -> ceftriaxone x1 and f/up in 24 hrs
Kawasaki disease
Fever 5+ days plus 4 of the following:
- polymorphous rash
- oral mucous membrane changes: strawberry tongue, cracking lips
- Peripheral extremity changes: redness, edema, desquamation
- B/l bulbar limbic sparing conjunctival injeciton
- Cervical LAD with 1.5+ cm usually U/L
Classical findings of Henoch-Schonlein purport (IgA vasculitis)
MC vasculitis - deposition of IgA immune complexes
Palpable purport without thrombocytopenia and coagulopathies predominantly lower body, below waist Artheritis/arthralgia abdominal pain renal disease
Cystic fibrosis
abnormal chloride transport -> thick viscous secretions
Frequent severe bronchitis with hospitalizations
very foul-smelling stools
hx of meconium ileus
Dx:
sweat chloride test with elevated Cl level
CFTR gene mutation
Acute OM
fever + pain
> HD amor 90 mg/kg/d 1st line
if older than 2y with mild sxs - observe and f/up prn
Scarlet fever
scarletina rash - diffuse erythematous blanching rash that is rough to touch and non tender on trunk and extremities sparing pals and soles
Very red, contender tongue, hx of sore throat with fever
Tx:
Amox or PCN V for 10-14 days
Should see improvement within 24-48 hrs of abx start
Patent ductus arteriosis
continuous machine like heart murmur heard mid left sternal border
MC in premies
Close with indomethacin or ibuprofen
Tetralogy of Fallot
MC cyanotic congenital heart defect
RV outflow tract obstruction - PS
RV hypertrophy
VSD with overriding aorta
Physiologic jaundice
benign
Starts 2-3 days of life, peaks at day 3-5
bili less than 10 - unconjugated
due to inadequate UDPGT enzyme that conjugates bilirubin
Tx:
phototherapy
Breast milk jaundice
benign
elevated bili at day 3-5 or later that persists for 3-12 weeks
bili less than 10
unknown substance in breast milk that increases intestinal absorption of bilirubin
Management of nocturnal enuresis
if exam normal -> enuresis alarm - wake up child to finish voiding
short term desmopressin for overnight sleep overs
Mecke diverticulum
painless GI bleeding in child
Hgb normal, no distress
Dx:
Meckle’s scan - nut med scan looks for gastric mucosa
if unstable - arteriography for source of brisk bleed
Developmental dysplasia of hip
Barlow maneuver - dislocates hip clunk on exam with posterior pressure while adducting flexed hip
Ortolani reduces
Next step: B/L hip US
Tx: abduction splint - Pavlick harness
Slipped capital femoral epiphysis
obese child with hip pain causing limp, waddling gait
Improved sxx with hip flexed and externally rotated
Restricted internal rotation of hip
XR hip: ice cream falling off cone
Tx:
Operative stabilization
TORCH infections
Toxoplasmosis Other (syphilis, Parvo B19, enteroviruses, VZV) Rubella CMV HSV
Hemolytic uremic syndrome
abdominal pain with blood diarrhea after eating contaminated meat
EHEC - shiga toxin
Labs: Hemolytic anemia Thrombocytopenia AKI Stool cx: EHEC
First step in evaluating a child with poor performance with attention problems
check hearing and vision
WAGR syndrome
Wilms tumor
Aniridia - absent iris
Genitourinary abnormalities: cryptorchidism, ambiguous genitalia, renal impairment
Retardation - intelectual disability
7 day old newborn with purulent discharge from eyes - management
Culture drainage - MC Chlamydia trachomatis at this age
ppx: erythromycin ointment - not used for active infections
PO erythromycin x14 days for active infection
Pertussis
Bordetella pertussis - severe cough with fits, gagging, “whoop” sound
Clears 3-4 weeks
Abx decreases transmission but does not change disease course, also given a sppx for those exposed
-Azithromycin OR clarithromycin
Fetal alcohol syndrome
short palpebral fissures thin vermillion border/upper lip smooth filtrum flattened mid face deficient brain growth: -structural brain abnormalities -less than 10th percentile for head circumference -abnl neuro exam -variable intellectual disability Growth retardation: -less than 10th percentile on height and weight -FTT despite adequate intake -disproportionally low wt:ht ratio
Strawberry hemangioma management
60% resolve spontaneous by 2 yrs, 90% by 9 yrs
Tx:
observation
if on eye or near eye and growing rapidly, consider PO propranolol
Teratogenic agent associated with ebstein cardiac anomaly
Lithium
Teratogenic agent associated with clear cell adenocarcinoma of vagina
DES
Teratogenic agent associated with microcephaly, intellectual disability, smooth philtrum
alcohol
Teratogenic agent associated with gray baby syndrome
chloramphenicol
Teratogenic agent associated with phocomelia (malformation of the limbs)
thalidomide
Teratogenic agent associated with craniofacial anomalies, fingernail hypoplasia, developmental delay
phenytoin
Roseola infant (HHV-6)
MC under 2yo
high fever but not ill appearing, when fever breaks develops diffuse pink rash that starts on trunk then spreads to entire body
Tx: supportive care
Brachial cleft cyst vs thyroglossal duct cyst
Brachial cleft cyst - lateral neck
Thyroglossal duct cyst: midline neck, moves with swallowing
- MC congenital neck cyst
- associated with ectopic thyroid tissue - MC in tongue
Measles
Prodrome - nonspecific fever, cough, conjunctivitis
-3 C’s: cough, coryza (rhinitis or irritation of nasal mm), conjunctivitis
Coplik spots - white grey spots with red base on buccal mucosa
Rash 4-5 days - erythematous, maculopapular starts with head then moves to feet - “pouring measles paint”
Tx: supportive +/- PO Vit A
Management of undescended testis
Most descend by 3-4 months, rarely come down after 6 mo
Surgery at 6 mo
Management of febrile UTI in pens
Tx: 3rd gen cephalosporin - cefixime, cefdinir, cetibuten
Renal/bladder ultrasound to r/o vesicoureteral reflux in:
- any less than 2yo with 1st febrile UTI
- recurrent febrile UTIs
- any UTI w/ FHx of GU dz, poor growth, or HTN
- any who don’t respond to abx
pediatric immunodeficiency associated with recurrent bacterial infections after the age of 6 months
X-linked (Bruton) agammagloblinemia
pediatric immunodeficiency associated with recurrent sinopulmonary infections + anaphylactic reaction to blood transfusion
IgA deficiency
pediatric immunodeficiency associated with thyme aplasia + t cell deficiency + hypocalcemia
Digeorge Sn
pediatric immunodeficiency associated with severe recurrent infections by a variety of organisms (bacteria, virus, fungus, protozoa)
SCID
pediatric immunodeficiency associated with thrombocytopenia + eczema + recurrent infections
Wiskott-Aldrich sn
Infant botulinum
occurs 2-8mo
Muscle weakness, poor suck, constipation, ptosis
Associated with contaminated soil, wild honey, home canned foods
Tx:
Close monitoring for respiratory failure
Botulinum IG
Absence seizure mangement
ethosuximide
If fails -> valproic acid
Adverse effects of stimulates used in management of ADHD
Insomnia - take early
Appetitie suppression - eat big breakfast
Decreased growth velocity - generally catch up later
Tics
Psychosis or mania
Biliary atresia
birth - 8 wks develop jaundice
stools become acholic, urine dark, scleral icterus
Labs: elevated conjugated bilirubin, elevated LFTs
Imaging: cholangiogram to diagnosis
Primary goal of treatment in gonadotropin-dependent precocious puberty
early maturation of the HP-gonadal axis in girls under 8, boys under 9
Assess future predicted adult height
risk early closure of ephyseal plates and short stature
Tx:
GnRH analog therapy - IM q1mo to prevent further development
Treatment of 21-hydroxylase defiency
95% congenital adrenal hyperplasia
Ambiguous genitalia
Tx starts immediately!
- glucocorticoid - hydrocortisone
- mineralocorticoid - fludrocortisone
Post-strep glomerulonephritis
Hematuria, proteinuria, edema, HTN 3 weeks after throat infection
Confirm with ASO titer
Tx: supportive
Na/H2O restriction
Loop diuretic if HTN
ddx IgA nephropathy - however this starts 1-2 days after URI
Duchenne muscular dystrophy
2-3 yo with proximal m. weakness, LE involvement
Previously normal milestones
Stands up from flor using hands to push himself up
PE: proximal muscle weakness in LE, calf m. hypertrophied
Tx: PO prednisone 0.75 mg/kg/d
Becker muscular dystrophy is a milder form in teens and early adulthood
Infectious mononucleosis
Pharyngitis, LAD, significant fatigue
Tx:
supportive
-NSAIDS +/- tylenol
-Rest
-Avoid contact sports - risk of splenic rupture
> return to non contact sports in 3 weeks, contact sports at 4 weeks - gradual return
-Impending airway compromise d/t severe pharyngitis - give steroids
Thrush
white papular lesions on palate and tongue
Tx:
Nystatin - oral suspension: 1 ml to each side of mouth QID x14 d
If unresponsive - fluconazole 6 mg/kg day 1, then 3 mg/kg for 2 weeks
Risk of unrepaired clinically significant atrial septal defect
Risk RVF/CHF
arrhythmias
Eisenmenger sn: Right to left shunt
paradoxical embolus/stroke
Respiratory syncytial virus (RSV) bronchiolitis
URI sxs
Lower airway inflammation: expiratory wheezing -> respiratory distress esp in young infants
Tx:
Supportive O2, IVF prn
NO ICS or racemic epi
PO steroids not recommended
Hirschsprung disease
Failure of neural crest cells to migrate during intestinal development
Enteric nervous system doesn’t develop properly -> ganglionic segment of colon that can’t relax normally
-> functional colonic obstruction
S/S:
Delay passage of meconium +/- chronic constipation
Bilious vomiting
FTT
Abdominal distention
Explosive stool or gas discharge following rectal exam “squirt” or “blast” sign
