COMSEP Cases Flashcards
Treatment for afebrile pneumonia
Afebrile pneumonia most commonly chlamydia trachomatis
Tx = azithromycin (bubble gum flavored, taken QD)
16 yo w/ nasal discharge, 103 F
-swollen red eye w/ not intact EOM
(a) Tx
Orbital cellulitis
(a) Tx = immediate surgical drainage then abx
12 yo w/ cough, CP, 101 F x 3 days
-CXR: diffuse interstitial markings
Community acquired pneumonia
Tx for allergic rhinitis
(a) 1st line
(b) 2nd line
Allergic rhinitis tx
(a) 1st line: 2nd generation anti-histamine (Claritin, Zyrtec, Allerga) that are not sedating
(b) 2nd line: Nasal Steroids (Flonase)
HUS triad
Hemolytic uremic syndrome:
- microangiopathic hemolytic anemia
- thrombocytopenia
- acute kidney injury
Which would you be more likely to overtreat
(a) Hand vs. leg bite
(b) Cat vs. dog bite
More likely to overtreat
(a) Hand bite
(b) Cat bite: pasturella infxn
Etiology of orbital cellulitis
(a) Direct
(b) Indirect
Orbital cellulitis
(a) Direct inoculation from trauma or surgery, hematogenous spread from bacteremia
(b) Indirect as an extension of infection in periorbital structures (aka from ethmoid sinus)
Treatment for atypical pnuemonia in children > 5 yoa
Macrolides: azithromycin (tastes like bubble gum, taken QD)
-or cephalosporins (ex: Ceftriaxone or cefurozime)
Etiology of HUS
Primary and secondary causes
primary = d/o resulting in complement dysregulation
secondary = infectious causes: shiga toxin, pneumococcus, EHEC, 90% cases by STEC = Shiga toxin-producing Escherichia coli
Why is an albumin test done on a pneumonia pt
Hypoalbuminemia if pleural effusion
What to look for in a kid w/ allergic rhinitis
Triad: allergic rhinitis, eczema, asthma- in pt or family
Barky cough
Buzzword for croup = acute laryngotracheobronchitis
Most common causes of otitis externa
Pseudomonas aeruginosa and staph aureus
Common presentation of PID
Pelvic Inflammatory Disease- fever and lower abdominal pain w/o URI symptoms (no urinary urgency or frequency)
Erythema Multiform
(a) Etiology
(b) Tx
Immune mediated d/o, somewhat of a spectrum
-step above uticaria, step below Steven Johnsons
Etiology: HSV
-10% are allergic rxns to drugs: NSAIDs, sulfa drugs
Treat w/ steroids
Tx for HUS
Hemolytic uremic syndrome- supportive tx
- peritoneal dialysis if needed
- platelet/RBC transfusion if needed
- fluid and electrolytes to maintain intravascular volume
Otoscopic findings of acute otitis media
TM appears bulging and erythematous (redness and bulging)
- aberrant light reflex
- pus line
Tx for pertussis
Tx for pertussis = Azithromycin
12 yo boy w/ pain below right knee when running and playing soccer
Osgood-Schlatter = benign inflammation of the tibial tubercle that occurs before the completion of the growth plates by 15-17 yoa
- knee pain increases w/ activity
- common after growth spurt, usually in athletic kids
- no constitutional symptoms of history of trauma
Most frequent complication of bacterial pneumonia
(a) Rare but serious complication
Bacterial pneumonia
Most frequent complication = pleural effusion (tx: pleurocentesis)
(a) Rare but serious complication = empyema = pus collection in pleural cavity
11 yo w/ ear pain and drainage from canal
(a) If in July
(b) If in December
11 yo w/ ear pain and drainage from canal
(a) July- swimmer’s ear = otitis externa
(b) December- perforated TM
- acute ear pain that resolves when TM perforates
2 key clinical features of HUS
Hemolytic uremic syndrome: 1-2 week prodrome of blood tinged diarrhea => acute onset of pallor, lethargy/irritability, decrease/absent urine output
-wouldn’t expected pallor (indicating anemia) from just tinged stool => hint that pt is hemolyzing
How to clinically distinguish transient synovitis and LCP
Transient synovitis (benign inflammatory joint) vs. Legg-Calve-Perthes (avascular necrosis of the hip) is time
- transient synovitis will typically self-resolve w/in 7-10 days
- if persistent from weeks to months = LCP
3 most common bacteria that cause otitis media
40% of otitis media are bacterial
Strep pneumo, nontypable H. flu, Moraxella
Most common bug to cause
(a) Bronchiolitis
(b) Croup
Most common cause of
(a) Bronchiolitis = RSV
(b) Croup = parainfluenza virus
Cough that wakes pt up at night
(a) 7 yr old
(b) 5 yr old
Cough that wakes up the pt at night
(a) 7 yo- sinusitis = mucous membrane inflammation of sinus cavity
(b) 5 yo- sleep apnea b/c tonsil size peak at 6
- sinuses not cavitated until 6
Differentiate when Prevnar 13 and pneumovac are given
Pneumococcal vaccines:
- Prevnar 13 given starting around 2 mo
- Pneumovax (23 serotypes) can be given after 2 yoa
Why should you not give Claritin D in kids w/ asthma
The “D” is for pseudophedrin which + albuterol = super hyperactive kid and increased cardiac risk (too high increase in BP or HR)
15 yo overweight M w/ hip pain
-no trauma or fever
SCFE = slipped capital femoral epiphysis
-femoral epiphysis slips posteriorly => limp and impaired internal rotation
Otitis media tx
(a) 1st line
(b) 2nd line
Treating otitis media
(a) 1st line = high dose amoxicillin -good gram (+) coverage
(b) If no improvement w/in 28 hrs: start Augmentin- adds E. coli and anaerobe coverage
3 week old male who squirms and grunts while having a BM
- soft stools
- child growing and thriving
Reassurance to parents, colic
6 week old afebrile infant
- hx of conjunctivitis
- px w/ staccato cough and tachypnea
- bilateral crackles, bilateral retractions
- CXR: patchy densities and hyperinflation
Afebrile pneumonia in infant = chlamydia trachomatis
Frequent finding in atypical or viral pneumonia
Wheezing
Causes of neonatal conjunctivitis
(a) w/in 6-12 hrs of birth
(b) 2-5 days
(c) 5-14 days
Neonatal conjunctivitis
(a) 6-12 hrs: chemical irritation from ocular silver nitrate
(b) 2-5 days: most serious- gonococcal conjunctivitis
(c) 5-14 days: chlamydial conjunctivitis
6 yo w/ pallor and irritability after week of abdominal pain and blood tinged diarrheal stools
HUS = Hemolytic Uremic Syndrome
Tx for imeptigo
Mupirocin = topical abx
What bugs are we worried about when ruling out sepsis in a 1 mo old?
GBS and E. Coli => use 3rd gen cephalosporins
Also Listeria
Spinal tap findings indicative of herpes simplex meningitis
Elevated white count w/ lymphocytic elevation + red cells
Tradeoff to not giving abx for an acute otitis media
60% of otits media cases are viral => some ppl watch and wait
Risk of not treating = rare but serious complication of mastoiditis
Differentiate the spinal tap findings in bacterial vs. viral meningitis
Spinal tap findings in
Bacterial meningitis:
- high white count, high polys
- high protein and low glucose
Viral meningitis:
- high white count, high lymphocytes
- glucose normal and protein slightly elevated
3 physical exam signs of meningitis
Physical exam findings of meningitis
- Nucchal rigidity- can’t bend head forward
- Kernig sign- pain/resistance upon extending knee
- Brudzinski’s sign- involuntary lifting of the legs when the head is lifted while pt in supine position
Prophylaxis for swimmer’s ear
Alcohol in the ear- drys out the ear
-pseudomonas can’t grow w/o water
Tx for 4 yo w/ sinus infection
Um impossible…can’t be a sinus infection under 6-7 yoa b/c that is when the sinuses open => probably URI
Most common cause of atypical/walking pneumonia
Mycoplasma pneumonia
- chlamydophila
- viral
Most common cause of pneumonia
(a) overall in peds
(b) Newborn period
(c) First few months
(d) 1 mo- 5 yr
(e) after 5 yrs
(f) pts w/ central lines
(g) CF/chronic lung disease pts
Etiology of pneumonia
(a) Overall peds = Pneumococcus
(b) Newborn: GBS, Enterobacteriaceae, HSV
(c) First few mo: Chlamydia trachomatis, viral
(d) 1 mo- 5 yr: viral, pneumococcus
(e) Over 5 yoa: mycoplasma
(f) Central line (ex: ICU)- psueodomonas, candida
(g) CF/chronic lung disease- pseudomonas, aspergillus
4 yo w/ cough and 104 F following URI prodrome
-r. sided crackles
Bacterial pneumonia: most likely pneumococcus (strep pneumo)
16 mo old w/ nasal discharge and foul smell for 3 days
Organic foreign object
Diagnostic test for testicular torsion
Doppler ultrasound
-shows velocity of blood flow
Pertussis
(a) clinical features
(b) febrile?
(c) CXR findings
Pertussis
(a) Paroxysmal cough, blue spells
(b) afebrile
(c) normal CXR
Name some risk factors for recurrent otitis media
- immunodeficiency
- Under 6 yoa (eustachian tubes get longer and angle down after 6 yoa)
- craniofacial abnormalities
Uticaria-like rash that is a bit more intense + mouth lesions
(a) Tx
Stevens Johnsons syndrome
-all mucous membranes affected: vaginal, eyes, mouth etc
Tx w/ IVIG
Tx of Kawasaki’s
Anti-inflammatory tx: IVIG + aspirin
Peds cardiology consult + echo as f/u to monitor for coronary aneurysm
Darth Vader breathing
= stridor
11 yo w/ springtime nasal congestion and itchy eyes
Allergic rhinitis
Treatment for chronic ear infections
- prophylactic abx
- singular
- tubes if kid is language delayed
9 mo old w/ 2 days of vom and diarrhea. HR 210
Gastroenteritis
-give fluids: compensatory HR will decrease
Easy way to diagnose/differentiate palpable abdominal mass
Easy differentiation of neuroblastoma and Wilm’s (w/o imaging)- urine test
-see increased catecholamine metabolites in urine = neuroblastoma
Differential for hip pain in children
(a) infectious
(b) inflammatory
(c) orthopedic
Infectious: septic arthritis, osteomyelitis
Inflammatory: transient synovitis, juvenile idiopathic arthritis
Orthopedic/mechanical: Legg-Calve-Perthes, stress fracture, SCFE (slipped capital femoral epiphysis)
Paroxysmal cough
Paroxysmal cough = intermittent, aggressive attacks
-buzzword for pertussis/whooping cough
6 yr old w/ abdominal pain for 6 weeks + episodic fecal soiling of underwear
-gaining and growing well
Encopresis = involuntary defecation
-see no anal tone on rectal exam, do anal wink test (stroke the anus to cause contraction) to r/o neurological cause for anal hypotonia
Most common site of osteomyelitis in children
Proximal femur
Why is a fever > 100.4 in 1 mo old concerning
1 mo old w/ fever over 38 C has an 8-10% chance of having a life-threatening infxn-
this is why we admit these and do sepsis workup
-blood culture, LP, UA
How to treat pneumococcal pneumonia
High-dose Amoxicillin + Clavulanic acid (Augmentin)
Ddx for young children turning blue
Cyanosis in young children:
- whooping cough (pertussis)
- breath holding spells
- reflux
- seizure
Etiologies of otitis media
(a) Breakdown of percent viral vs. bacterial
(b) 3 most common bacterial causes
60% viral
40% bacterial
40% bacterial:
- strep pneumo
- moraxella
- non-typable H. flu
(same bugs for ear and sinus infections)
7 yo w/ hip pain + limp
-no trauma, fever, PMH
Transient synovitis = dx of exclusion (r/o septic arthritis)
-afebrile
6 yo w/ fever, HA, sore throat
- raised rough red rash on trunk and abdomen
- no URI symptoms
Scarlet fever
-sandpaper rash
2 yo w/ abrupt onset cough, wheeze, tachypnea
- afebrile
- wheezing on right
Foreign body aspiration
- sudden onset
- unilateral
Lab tests to diagnose HUS
CBC: Hgb/Hct (low), platelet count (low)
- peripheral blood smear: schistoytes
- renal fxn studies: elevated BUN and creatinine
- urinalysis: proteinuria
Tx of intussusception
Air enema
Concerning complication of Kawasaki’s
Coronary artery disease
-develops in 5% even w/ tx (possibly higher w/o tx)
SCFE
(a) typical pt
(b) Xray finding
SCFE = slipped capital femoral epiphysis
(a) obese adolescent
(b) posterior displacement of femoral epiphysis- looks like ice cream slipping off a cone
Describe the atopy triad
Either pt or family hx findings that commonly come together:
- eczema
- allergic rhinitis
- allergic asthma
Ddx for wheezing
(a) under 2 yoa
(b) > 1 yoa
(c) Any age
Wheezing
a) Under 2 yoa: bronchiolitis (RSV
(b) Over 1 yoa: asthma
(c) Any age- foreign aspirate
15 yo F twists her ankle while playing basketball
Name 2 indications for X-ray
Indications for Xray
- inability to bear white
- ability to localize tenderness: open hand vs. finger localization
First line tx for peritonsillar abscess
Need to cover staph/strep + anaerobes =>
Augmentin (Amox-Clavulanate) covers MSSA, strep, E. coli and anaerobes
Could also use clindamycin: broad gram (+) + anaerobe coverage
(doesn’t cover E. coli but covers MRSA)
15 mo old treated for acute otitis media 3 weeks ago
-TM look dull, gray, and have poor mobility
Otitis media w/ effusion- common complication of acute otitis media
- no fever or air pain
- usually takes a few more weeks to resolve (self-resolve)
If worried about hearing loss- can do tympanostomy drain
6 mo old former 28 weeker presenting w/ URI symptoms
- tachypnic w/ retractions, crackles, and wheezes
- CXR: bilateral perihilar streakiness and hyperinflation
6 mo old premie w/ URI symptoms
Perihilar streakiness + hyperinflation = bronchiolitis
Tx for otitis externa
Ofloxacin or Ciprofloxacin- both fluoroquinolones w/ good gram (+) and (-) coverage
-cover for pseudomonas
Tx of croup
Cool air or humidity for cough and stridor
-corticosteroids
4 yo w/ diffuse pruritic rash
-raised erythematous lesions w/ serpiginous borders and blanched center
Snake-like borders w/ blanched center (central pallor) = uticaria (hives)
Cushing’s triad
Cushing’s triad/reflex = response to increased ICP
hypertension, tachypnea, bradycardia
8 yo F w/ abdominal pain, purpuritic lesions on buttocks and legs, knee and ankle pain
-darker urine
HSP
- abdominal pain: common ileo-ileal intussuception
- hematuria b/c of kidney involvement
Osgood-Schlatter
(a) Physical exam findings
(b) Tx
Osgood-Schlatter
(a) Pain reproducible by putting resistance on the patellar tendon: extending knee against resistance, squatting w/ knee flexed
(b) Tx: rest, ice after activity, NSAIDs, knee immobilization if severe
Differentiate abx choice for sepsis in 1 mo old vs. 2 mo old
Covering GBS and E. Coli => use 3rd gen cephalosporin in both, but a dif 3rd gen
Ceftriaxone = go-to 3rd gen, but can’t use in under 1 mo b/c of biliary sludging
For under 1 mo use Cefotaxime
To cover for Listeria add Ampicillin
Empiric treatment for meningitis in an 8 year old
Ceftriaxone (3rd gen cephalo) + acyclovir (covers HSV) + vanco (covers resistant pneumococcal disease aka MRSA)
