Exam 2: Lectures Flashcards
-Type of allergic reaction
-Trigger/antigen exposure causes allergy cascade that results in tissue injury from inflammation and hyper-responsiveness
-Genetic, environmental, and immunologic factors are involved
Atopic disorders
-Chronic inflammatory changes in the connective tissues
-Exact patho is unknown, but believed to be autoimmune
-Clinical presentation is due to autoantibodies
Rheumatic autoimmune disorders
-Inflammation of nasal epithelium d/t release of chemical mediators from antigen-antibody reactions
Allergic rhinitis
Clinical findings:
-rhinorrhea
-nasal pruritus
-congestion
-sneezing
Allergic rhinitis
Allergic rhinitis management
Avoid triggers
Oral or intranasal antihistamines
Intranasal corticosteroids
Leukotriene inhibitors
Immunotherapy (allergy shots) for severe symptoms not responsive to other methods
-Acute and chronic skin eruption that disrupt the protective ability of the skin
-65% of patients will develop symptoms w/in the 1st year of life
-1/3 of patients will develop asthma in addition to this disorder
Atopic dermatitis
Clinical findings:
-Pruritus
-Eczematous changes in the skin
-Acute: itching, erythema, papule/vesicle/edema, generalized dryness, serous discharge and crusting
-Chronic: lichenification, excoriation, generalized dryness
Atopic dermatitis
Management of atopic dermatitis:
Cotton clothing
Hydrate skin (emollients, ointments)
Pharmacologic anti-itch medication
Topical low-potency corticosteroids (high-potency will dry skin further)
Autoimmune disease
Onset in children < 16 y/o with chronic inflammation for at least 1 synovial joint for 6 weeks
Girls > boys
Juvenile Rheumatoid Arthritis (JRA)
+Rheumatoid factor and ANA are present in what type of JRA?
Polyarticular
Oligoarticular
Polyarticular
Systemic
Enthesitis
4 types of JRA
Management of JRA
Refer to rheumatology and PT
NSAIDs, oral corticosteroids can help with inflammation
-Chronic systemic autoimmune disorder
-ANA production and multi-organ system involvement
Systemic lupus erythematosus (SLE)
Clinical findings:
-Organ involvement dependent
-Butterfly rash to face is common
-Photosensitivity
-Mouth ulcers
-Arthralgia
-low grade fever
-fatigue/malaise
-anorexia/loss of weight
-joint pain/stiffness
SLE
+ANA in 97% of children with this disorder
SLE
Management of SLE:
-Refer to pediatric rheumatology
-Will need pain management
Clinical findings:
-Myofascial pain
-Fatigue
-Trigger points on PE
-Vague and/or variable multi-organ involvement
Fibromyalgia syndrome
Diagnostic criteria:
-3 months or longer
-Hx of pain
-11-18 trigger points
-Exclusion of other disease processes
Fibromyalgia syndrome
Management of fibromyalgia syndrome:
PT
Therapy
NSAIDs
Severe persistent fatigue not relieved by sleep or rest with the presence of 4 of 8 symptoms of criteria for diagnosis
Chronic fatigue syndrome (CFS)
Management for CFS
Psychologic support
Exercise
Autoimmune inflammatory process triggered as a complication of Group A Strep
Diagnosed based on Jones criteria
Acute Rheumatic Fever
Management of acute rheumatic fever
Antibiotics to treat Group A Strep
Anti-inflammatory therapy for arthritis
CXR, echo, and EKG for heart monitoring
Refer to cardiology for changes in CXR, echo or EKG
Systematic vasculitis in kids
Dx with clinical findings
Etiology is unknown
Henoch-Scholein Purpura (HSP)
Clinical findings:
-Palpable cutaneous purpura concentrated on dependent areas of the body
-Arthritis
-Colicky abdominal pain
-Vomiting
-Hematuria
-gross or occult GIB
HSP
Management of HSP
-Admit if moderate GIB or renal involvement
-Follow up UA and BP for 3 months after symptom resolution
-Self-limiting for 3-4 weeks normally
MCV < 78 fL
Microcytic
MCV 78-98 fL
Normocytic
MCV > 98 fL
Macrocytic
MCV is the…
RBC size
MCH is the…
Hemoglobin weight of the RBC
If a reticulocyte count does not improve with treatment of the anemia, what is the concern for in regards to the RBC?
RBC production (concern for marrow or splenic issues)
Acute anemia is most common in which age group?
Newborns d/t blood loss at birth and shorter RBC lifespan
Common cause of anemia in infancy:
Nutritional anemia d/t rapid growth and dietary adjustments are occuring
Common cause of anemia in early childhood:
Infections
Common cause of anemia in adolescents:
Rapid growth leaving them vulnerable to nutritional anemia
Adolescent females at risk of anemia 2/2 heavy menstruation
How does growth affect RBCs?
Increased need for RBC mass
H/H 2 standard deviations below the reference range for a specified age group
Anemia
Where does erythropoiesis occur?
Spleen and liver
Declines significantly after birth
Where does hematopoiesis occur?
Bone marrow
Beta thalassemia is more prevalent in which populations?
Black and Mediterranean descent
Alpha thalassemia is more prevalent in which populations?
Black and Asian descent
Red cell enzyme defects (G6PD, sickle cell trait) are more prevalent in which populations?
Mediterranean, African, and southeast Asian
Besides OLDCARTS, pallor, fatigue, lethargy, dizziness, anorexia, jaundice, urine color, and FTT, what is an important aspect to assess when considering anemia in children?
Loss of milestones and growth
Focused assessment for anemia should include:
Skin, eyes, mouth, face, chest, hands, and abdomen
Differentials:
-Diamond-Blackfan anemia (congenital pure red cell aplasia)
-Transient erythroblastopenia of childhood
-Aplastic crisis (may be seen with Parvovirus B19)
Marrow failure
Generally develops gradually, chronic anemia
Differentials:
-Anemia of chronic disease in renal failure
-Chronic inflammatory diseases
-Hypothyroidism
-Severe protein malnutrition
Impaired erythropoietin production
Differentials:
-Nutritional anemia (2/2 iron, folate, or Vit B12 deficiency)
-Congenital dyserythropoietic anemia
-Sideroblastic anemia
-Pure red cell aplasia/maturational arrest
Defect in red cell maturation
Iron deficiency anemia and thalassemias are…
Microcytic (MCV < 78)
Folic acid and Vitamin B12 deficiencies are…
Macrocytic (MCV >98)
Genetic deficiency
Alpha or beta chain affected (alpha chain is not compatible with life)
Leads to premature RBC death
Thalassemias
Normal Hgb (11.5-14.5)
Low MCV (< 78)
Thalassemia
Normal Hgb
High MCV
Aplastic anemia
High Hgb (> 14.5)
Low MCV
IDA, HgH disease, sickle beta thalassemia
High Hgb
Normal MCV
Liver or chronic disease
High Hgb
High MCV (> 98)
Folate or Vitamin B12 deficiency
Do children normally have a severe reaction to COVID-19?
No, they’re generally asymptomatic or mild in symptoms with a 1-2 week duration of disease
Clinical findings:
-Persistent fever
-Hypotension
-GI symptoms
-Rash
-Myocarditis
-Labs showing increased inflammation
Multisystem inflammatory syndrome in children
If a patient presents with MIS-C what is the next step?
Transfer to hospital as this is a serious condition
Can paxlovid be given to children?
Yes if they are 12 years or older and have risk factors that put them at increased risk of severe disease development
Vaccine type:
MMR, OPV, varicella, flumist, rotavirus
Attenuated, weakened live virus
Vaccine type:
IPV, Hepatitis A
Killed, inactivated
Vaccine type:
DTap and TDap
Toxid, toxin produced by bacterium
Vaccine type:
HIB, Hep B, influenza, pertussis, pneumococcal, meningococcal, HPV
Subunit and conjugate
Diseases: hand-foot-mouth, herpangina, pleurodynia, acute hemorrhagic conjunctivitis, pericarditis, viral meningitis, pancreatitis, orchitis, neonatal sepsis
Transmission: fecal-oral and respiratory droplets
Increased prevalence in the summer and fall
Enteroviruses
Clinical findings:
Sudden onset high fever
Fever lasts 1-4 days
Loss of appetite
Sore throat
Vomiting
Diarrhea
Rash on tonsils, uvula, pharynx and soft palate
Herpangina
Clinical findings:
-Fever
-Vesicular eruption on buccal mucosa
-Maculopapular rash that moves to a vesicular rash of the hands and feet
Hand-foot-mouth
Primary infection in the liver
Highly contagious
Spread through person-to-person contact via fecal-oral, food, and water
Hep A virus
Clinical findings:
Preicteric: acute febrile illness
Jaundice phase: appears shortly after onset of symptoms
Hep A virus
What diagnostics are used for Hep A?
IgM and IgG for Hepatitis A
Management of Hep A:
Supportive care
Gamma globulin w/in 2 weeks of exposure (prior to symptoms and diagnosis)
Cause of sever liver disease
Highly contagious
Spread through mucous membranes exposed to blood or sexual secretions
Large decline in the US d/t vaccination rates
Hep B virus
You are testing your patient to rule out Hep B. They come back with a Anti-HBs positive. Do they have an active Hep B infection?
No, this shows proper immunity
When is the primary infection period for children with HSV-1?
Infancy to 4 years old
When obtaining a viral culture of a vesicle to rule out HSV-1 or HSV-2, what is the best section of the vesicle to sample?
The fluid if it is open and draining to determine the causative agent
What is the causative agent of mono?
EBV (Epstein Barr Virus)
Clinical findings:
-Fever
-Sore throat
-Lymphadenopathy
-Splenomegaly
-Hepatomegaly
-Skin rash
-Periorbital edema
-Abdominal complaints
-Fatigue
-Weakness
Mono
You have a patient come into your office with fever, sore throat, and lymphadenopathy. Strep test is negative, rapid monospot is positive. The patient is a 15 y/o F who plays basketball and wants to know when she can return to play. You tell her:
At least 4 weeks to prevent possible splenic rupture as mono can increase risk of splenomegaly
HHV-6 and HHV-7
Most show + HHV-6 titers
Roseola Infantum
Clinical findings:
-Sudden onset fever 101-103 for 3-6 days
-Lymphadenopathy
-Lethargy
-Vague GI complains
-URI symptoms
-Rash that starts after fever breaks
-Rash: diffuse, nonpruritic, maculopapular begins on trunk and spreads to extremeties, lasts 2-3 days
Roseola Infantum
What is the management for Roseola Infantum?
Supportive care
Common and highly contagious
85% decrease in infections since vaccine
Spread by droplets, contact, airborne
Varicella
Small pruritic, vesicular, red rash
Varicella
You have a young patient who comes in with a pruritic, vesicular, red rash all over. Their immunizations are up-to-date, but they are too young to have recieved their varicella vaccine. They attend day care where there has been a recent chicken pox outbreak. You diagnosis the child with chickenpox. The parent asks if they can give the child aspirin to help with the inflammation. What would you advise?
The parent should avoid aspirin as this can cause Reyes syndrome in children taking aspirin with varicella
You have an 11 y/o F who presents today with a pruritic, vesicular rash to her T6 dermatome on the L side of her back. She states she had been playing out in the woods and thought it was just poison ivy. When she itches the rash, it burns and hurts. Her IUTD, she has a PMH of chickenpox at 5 months old. She is presently going through puberty placing stress on her body. Although rare, you suspect she has shingles because:
Shingles is a reactivation of the latent varicella virus that she contracted at 5 months old, she is under stress that can trigger shingles activation, and the rash is vesicular on a dermatome, not crossing the midline.
Clinical findings:
Sudden onset high fever
Headache
Chills
Coryza
Vertigo
Sore throat
Body aches
Vomiting
Diarrhea
Anorexia
Cough
Flu
Can tamiflu be prescribed to children?
Yes for children 2 weeks of age or older with symptom onset in < 48 hours
On a newborn screening, the newborn screens positive for HIV. Who should be primarily managing their care?
Pediatric HIV specialist
You are meeting a newborn for their first post-hospital wellness visit. When obtaining a history you find that the baby is on Zidovudine daily for the next 6 weeks. You see their newborn screen is positive for HIV and mom shares she is HIV +. You understand the baby is on Zidovudine as:
A prophylactic measure as mom’s antibodies will continue to circulate out baby’s system over the next few months
What is the most contagious disease of childhood?
Measles
Cough, coryza, conjunctivitis
3 C’s of measles
Diagnostic testing for measles:
IgG, IgM antibodies
IgG decreases after acute phase of infection
Clinical findings:
-Maculopapular rash that coalesces
-Starts behind ears, travels to forehead
-Rash moves in a cephalocaudal pattern
Measles
If the child is exposed to measles and is eligible for vaccination, how long of a period do you have to get them vaccinated?
72 hours from exposure
Painful enlargement of the salivary (parotid) glands
Mumps
You just diagnosed a patient with mumps. The parent wants to know when the child can return to daycare as the parent will have to be out of work to care for the child. You advise:
The child can return to daycare/school after 9 days from the onset of parotid swelling
What are the diagnostic tests for mumps?
IgG, IgM antibodies
Elevated amalaise
Lymphocytosis
3 stages of Rubella
Prodrome, lymphadenopathy, rash
“slap cheek” rash is characteristic of…
Fifth’s disease/erythema infectiosum
How long will B19-specific IgM be present in the body after contracting parvovirus B19?
6-8 weeks
If you have a patient that comes in with an unknown tick bite and erythema migrans rash, do you need to preform any other diagnostics?
No, erythema migrans is diagnostic for Lyme
What is a key factor in tick-borne illness transmission?
Length of time the tick is attached/imbedded
Primary treatment for Lyme disease is:
Doxy
If you suspect Lyme disease, but there is in no EM rash present, what would you order?
- ELISA, if positive then,
- Western blot for Lyme
When treating for MRSA, what is a diagnostic needed prior to abx initiation?
Wound culture and sensitivity
What age is meningococcal most prevalent in children?
11-23 y/o
Does the meningitis vaccine protect against all strains of meningococcal disease?
No
You complete a PPD on a child that is 8 y/o. They come back for the reading of the PPD and they are found to have induration of 10mm. Is this a positive test?
No this is a negative test
What level of induration is present in a positive PPD for a child older then 4 y/o?
> 14mm
What is the level of induration present in a positive PPD for a child younger then 4 y/o?
> 10mm
What is fever of unknown origin (FUO) defined as?
Fever for most days for 3 or more weeks
No known cause after extensive workup
Fever without focus and fever of unknown origin require what kind of history and physical?
Comprehensive and detailed
Diagnostics to consider for fever without focus:
CBC, blood cultures, UA, stool culture (or stool sample with diarrhea present)
Diagnostics to consider for fever of unknown origin:
CBC with diff
ESR
Blood cultures
CSF studies
UA and culture
LFTs
EBV titer
CMV titer
ASO titer
CXR
UTI, pyelonephritis, URI, localized infection, JRA, and leukemia are the most common cause of what in children less then 6 y/o
Fever of unknown origin
What is the leading cause of heart disease in children?
Kawasaki’s disease
Clinical findings:
-Conjunctival hyperemia
-Erythematous rash
-Edema of the hands and feet
-Polymorphous erythematous rash
-Unilateral lymphadenopathy
Kawasaki’s disease
Characteristics:
Brachycephaly
Flat nasal bridge
Small ears
Cardiac anomalies
Trisomy 21
Characteristics:
Mental retardation
FTT
Prominent occiput
Small features
Trisomy 18
Survival rate for Trisomy 18:
5% survive the 1st year of life
Characteristics:
Mental retardation
Capillary hemangiomas
Cleft lip/palate
Deafness
Trisomy 13
Characteristics:
Broad chest
Webbed neck
Lymphedema of hands/feet
Lower hairline
Urinary tract anomalies
Turner’s syndrome (XO)
Characteristics:
Usually identified when testes fail to enlarge
Typically tall and lanky
Sterile
Learning disabilities
Klinefelter syndrome (XXY)
You have a 10 y/o F who comes in for her annual well-care visit. She is c/o pain in her legs. She has grow significantly since her visit last year. Her current Tanner stage is 3, last year she was a stage 2. You know her leg pain is most likely r/t what and will last approximately how long (intermittently)?
Her leg pain is r/t growing from growth spurts. Her growth spurt probably started last year when she was Tanner stage 2, will peak around Tanner stage 4 and end when she reaches Tanner stage 5.
You have an 11 y/o M who presents today for his annual well-care visit. He is presently healthy, Tanner stage 1. He is wondering why his female peers are getting taller then him and wants to know when he will start growing more. You tell him that at what stage will his growth spurt occur?
Tanner Stage 3
Unilateral shortening and fibrosis of the sternocleidomastoid muscle d/t:
Intrauterine crowding
Muscle trauma during difficult delivery
Soft tissue compression leading to compartment syndrome
Congenital abnormalities of soft tissue differentiation within the SCM muscle
Congenital muscular torticollis
Treatment for CMT?
Referral to PT for repositioning, ROM, strengthening
If your patient has CMT at birth that is not resolved with PT by age 1, what is the next step?
Referral to ortho for probable surgical intervention
Why are clavicular fractures common in infants?
It is the first bone to ossify and can be broken during birth, infancy, and childhood
How do most fractures of the upper extremities occur in children?
Falling on an outstretched arm/hand (FOOSH)
You have an infant with a clavicular fracture at birth due of LGA. The parents have been keeping the child’s arm immobilized by pinning the sleeve of the onsie to the body of the onsie. The child is brought into the practice 2 weeks after birth for follow up. What will you recommend in regards to motion?
The child can be unpinned and no longer needs to be in a sling, immobilization was only needed for the first 1-2 weeks.
A 14 y/o M hockey player presents to the practice day 2 post-injury. He was elbowed from above and seen in the ED 2 days ago with a confirmed clavicular fracture. The ED placed him in a sling. He is wondering how long he will have to wear his sling for and when he can return to play.
He will need to be in the sling for 3-4 weeks with repeat x-rays to show evidence of healing. At the 4 week mark, he can start PT with gentle ROM. It could take up to 6-12 months for full callus formation and will be out for the rest of the present season.
Skin tag or fully formed extra digit
Genetic disorder
Treated with a ligation suture for removal
Polydactyly
Digits (fingers or toes) fused by skin or bone
Autosomal dominant inheritance pattern
Cosmetically fixed by plastics, preferred until older and child can help with post-op
Syndactyly
Digit locks and catches when flexed/extended
Most commonly seen in the thumb
Tx: Refer to ortho for possible surgery to prevent contractures
Congenital trigger finger
Abnormal curvature of the spine present at birth
Congenital scoliosis
One or more vertebra don’t completely form causing a sharp angle to form in the spine that can worsen with growth
Hemivertebra
Scoliosis treatment involves:
Referral to orthopedic surgeon
Bracing if not severe curvature
Scoliometer is useful in diagnosing scoliosis to help with what process?
Determining who needs x-ray
Disproportionate short stature
Autosomal dominant disorder
Avg height: 4 ft
Achondroplasia
When charting growth for a child with achondroplasia, do you use the WHO and CDC growth charts?
No, achondroplasia has it’s own growth chart that has been developed
You have a 2 y/o F with achondroplasia who is brought in today by the parent. The parent expresses concerns that the child is not walking independently and her words at not fully comprehensible. The child has 2 older siblings without achondroplasia and the parent is concerned there is something wrong with their daughter. What is your response to this parent?
Walking independently may be delayed until 2-3 y/o in children with achondroplasia d/t their hypotonic ligamentous laxity and larger head making if difficult for them to balance. Her language is developing, but may be more difficult to understand d/t tongue thrust. This should resolve in the next few years as she continues to grow.
How often do you examine the hips in a child?
Every well-child visit from birth to 2 y/o
Ortolani, Barlow, and Galezzi are all maneuvers for:
Hip displacment
You have a newborn who has a subluxation of the L hip s/p birth. The parent is wondering if there is anything that needs to be done. You inform them that the next step is:
Watchful waiting, most birth subluxations will spontaneously correct in about 2 weeks
The infant you saw 2 weeks ago is back for a follow-up. Their subluxation has not resolved. What is your next step?
Referral to ortho for possible Pavlik harness or spica cast
You have a child who comes in for their 9 month well-child exam. On exam you find a positive Ortolani. What is the next step?
Send to ED for reduction of the hip follow by hip spica casting with referral to ortho
You have a 13 y/o M who presents today with his mom after noting that her son has been limping a lot more recently. He is slightly overweight, Tanner Stage 2, and denies c/o pain unless he is running at lacrosse practice. On exam you a limp in gait and slightly uneven legs. You order an x-ray that shows a posteriorly displaced femur with a SH Type 1. You diagnose the child with a SCFE with what next steps?
Immediate immobilization and urgent referral to ortho surgery knowing that SCFE have an increased risk of AVN and needs surgical intervention asap to prevent bone collapse
Bowlegged
Genu varum
Knock kneed
Genu valgum
When is it normal to see a child presenting with genu varum (bowlegging)?
Up to 2/3 y/o
When is it normal to see a child presenting with genu valgum?
4-6 y/o (preschool age)
Varus degree > 15
Angle does not decrease by 2nd year of life
Asymmetric
Short stature
Rapidly progressing
Red flags for pathologic disease causing genu varum
You have a 3 y/o F presenting with genu varum. It is measuring at 18 degrees. The parent has no complaints and says the child is moving well independently. What is the next step?
Refer to orthopedics for assessment
Older then 6/7 y/o
Tibial-femoral angle > 15 degrees
Increasing severity
Short stature
Asymmetric
Obesity
Red flags for pathologic causes of Genu valgum
Your patient is coming in for their 7 y/o well-child visit. On exam you noted genum valgum is still present. The child has no complaints and mentions that they love playing soccer. You measure the tibial-femoral angle and find it to be 17. What is the next step in their treatment plan?
Bracing at night
Abnormal medial rotation resulting in an in-toeing of the feet, primarily noted when walking
Medial tibial torsion
Abnormal lateral rotation resulting in an out-toeing of the feet, primarily noted when walking
Lateral tibial torsion
What is the treatment for tibial torsion?
Referral to orthopedics to help with alignment, stretching, and possible surgical intervention
Does lateral tibial torsion spontaneously resolve or resolve with stretching?
No only medial does
Complicated, multi-factorial deformity of primarily genetic origin
Components:
-Ankle joint plantar flexed
-Subtalar joint inverted
-Forefoot abducted
Club foot
When are the joints most flexible for initiating correction of childhood MS deformities
Birth-first few days of life
C-shaped lateral aspect of the foot
Congenital foot deformity
Metatarsus adductus
How is metatarsus adductus treated?
Stretching of the foot, specifically overstretching laterally to “open” the C-shape 5x with each diaper change for at least 8 months
If does not resolve in 4-8 months: refer to ortho
Congenital bone fragility disorder
Clinical findings: frequent fractures, bruising easy, deafness
High prevalence of abuse concern
Osteogenesis imperfecta
Is there a cure for OI?
No, there is no cure and needs an interdisciplinary team approach to care
Child lies supine with hips and knees flexed
+: knee on affected side is lower
Galezzi’s sign
Idiopathic, avascular necrosis (AVN) of femoral head
Legg-Calve-Perthes disease
Clinical findings:
Acute: sudden onset of groin or knee pain, pain at night w/ weight bearing or stiffness, some restriction of hip ROM
Chronic: recurring mild/aching hip pain referred to knee/thigh/groin, limp, stiffness in AM or after rest
Legg-Calve-Perthes disease
PE findings:
Antalgic gait w/ leg shortening
+ Trendelenburg
Muscle spasms
Thigh atrophy
Limited hip abduction, internal rotation and extension
Pain with leg rolling
Short stature
Legg-Calve-Perthes disease
You suspect your patient has Legg-Calve-Perthes disease, what is the next step in your management plan?
Immediate referral to orthopedics
Salter-Harris Type:
Break the bone through growth plate, no shift of the bone
Often not visible on x-ray
Generally heals well
Treated w/ cast immobilization
Type 1
Salter-Harris Type:
Break through part of the bone at the growth plate and crack through the bone shaft.
Generally heals well, may need surgical intervention
Most common type of growth plate fracture
Treated w/ cast immobilization
Type 2
Salter-Harris Type:
Break through the bone at the growth plate, separates bone end from bone shaft and completely disrupts the growth plate.
May result in arrested growth
Treated with surgery
Type 3
Salter-Harris Type:
Cross through portion of growth plate and break off piece of bone end
More common in older children
Treated with surgery
Type 4
Salter-Harris Type:
Break through bone shaft, growth plate, and end of bone.
Commonly results in arrested growth of the bone.
Treated with surgery with internal fixation
Type 5
Salter-Harris Type:
Similar to Type 5, but broken pieces are missing
Open or comminuted fracture
Requires surgery for repair and fixation with possible reconstructive surgeries
Type 6
Pain in the posterior aspect of the heel
Common in athletes 5-11 y/o
Tenderness on medial and lateral compression of posterior calcaneus
Sever’s disease
Inflammation of the tibial tuberosity
Common cause of knee pain in pt 10-15 y/o
Caused by repetitive microtrauma
Osgood-Schlatter’s disease
Stretching of a ligament
Sprain
Stretching of a muscle or a tendon
Strain
PRICE
Protection, rest, ice, compression, elevate
Most ankle sprains occur in which fashion?
Inversion of the foot
Sprain classification:
Partial tear
Joint stable, minimal pain, swelling and ecchymosis
Slight or no functional loss
Able to bear weight with minimal pain
1st degree
Sprain classification:
Incomplete tear
Moderate functional loss
Joint stable
Severe swelling > 4cm and ecchymosis
2nd degree
Sprain classification:
Complete tear
Loss of ligament integrity
Unstable joint
Loss of function and motion
Unable to bear weight
3rd degree
Ligament grading:
Stretching of fibers w/o significant structural damage
Grade 1
Ligament grading:
Partial disruption of fibers w/ increased instability
Grade 2
Ligament grading:
Complete tearing of ligament with significant instability
Grade 3
Knee ligament tear:
Foot planted
Knee flexed
Changes direction applying rotational force to the knee
2nd most common knee injury
ACL tear
Knee ligament tear:
Blow to anterior proximal tibia with knee flexed
PCL tear
Knee ligament tear:
Valgus stress or external rotational force with legs firmly planted
Frequently football and basketball injuries
Often associated with an ACL injury
Most common knee injury
MCL tear
Knee ligament tear:
Varus stress or rotational force sustained with feet planted and hyperflexed
LCL tear
Excessive lateral traction applied to neck and shoulder during birth
Paralysis or weakness of muscles innervated by spinal nerves C5-8 and T1
Brachial plexus injury
Clinical findings:
Unable to abduct arm from shoulder or rotate arm externally
Keeps shoulder in adduction and internal rotation, extension of the elbow and flexion of wrist and fingers
Limp wrist and hand with absent grip reflex
Brachial plexus injury
What is the treatment for brachial plexus injuries?
Splinting for 2 weeks (minimum)
PT
Most cases spontaneously resolve
Hallmark symptom: gradual onset of pain in the shoulder
Subacromial impingement
What sport are humeral fractures commonly seen with?
Baseball as an overuse injury from throwing
Most commonly dislocated joint in pediatrics
Forceful abduction and external rotation (w/ or w/o fall)
Glenohumeral dislocation/subluxation
Clinical findings:
Pt holding arm in cradle-type position
Unable to actively more arm
Pain with passive ROM
Tender fullness palpated in anterior axilla
Glenohumeral dislocation
Treatment of glenohumeral dislocation
Reduce and immobilize
Transport to ED for reduction
Clinical findings:
Swollen, painful elbow
Obvious deformity
Limited ROM
Palpable depression over triceps
Presence of ecchymosis
Supracondylar fracture
Clinical findings:
Acute medial elbow pain
Unable to continue to play sport d/t pain
Inflammation involving ulnar nerve with numbness to ring/pinky finger
Local, minor swelling
Tenderness on palpation
“Little Leaguer’s Elbow”
Swollen elbow
Localized lateral tenderness
s/p FOOSH
Thurston-Holland fragment on x-ray
Lateral condyle fracture
Subluxation of proximal radial head
Commonly in ages 1-4 y/o
Sudden traction on outstretched arm while pull of radius distally causes slipping of the annular ligament
Nursemaid’s elbow
Can nursemaid’s elbow be reduced in the office by the PCP?
Yes
Most common fracture of childhood:
Forearm fractures
In children prior to adolescents, is back pain a common complaint?
No, this should be a red flag in younger children
In adolescents is back pain normally muscular, neurologic, or bone related?
Muscular
Unilateral pain over posterior elements of lower lumbar vertebrae during single-leg hyper-extension causing pain near L4/5
Stork test
When is the stork test used?
Testing for spondylolysis
What is the treatment for spondylolysis?
Rest, back bracing (specifically anti-lordosis extension), PT
Can return to exercise when pain-free for 2-3 months
Return to play 6 months after diagnosis
Refusal to walk or crawl ( <3 y/o)
C/O abdominal pain and tenderness of hamstrings (>3 y/o)
Fever, irritability
Symptoms relieved with prone position
Discitis
What is the treatment for discitis
Abx for 3-4 weeks (generally cephalosporin 4x/day)
NSAID/Tylenol for pain
Bed rest for 3 weeks
Concussion Grade:
No LOC
Symptoms resolve in < 15 min
Difficult to recognize appropriately
Grade 1
Concussion Grade:
No LOC
Symptoms persist > 15 minutes (longer then 1 hr, require medical obeservation)
Grade 2
Concussion Grade:
LOC
Grade 3
Racoon eyes
Blood in external ear canal (Battle’s sign)
CSF leakage in ears or nose
Cranial nerve palsies
Possible fx on xray
Basilar skull fracture signs
Multiple injuries
Varied stages of healing
FTT
Retinal hemorrhage
Burns, bruises, welts, bald spots, human bite marks
Vague complaints: ab pain, sleep disturbances
Clothing inappropriate for season
Behavioral issues
Signs of abuse
Female Tanner Stage 1
Breast: pre-pubertal
Pubic hair: pre-pubertal, no hair or villus hair only
Female Tanner Stage 2
Breast: breast bud stag
Pubic hair: scant amount of downy, straight hair along the labia
Female Tanner Stage 3
Breast: further enlargement of the breast and areola
Pubic hair: darker, coarser, curly hair that spreads sparsely across the central region
Female Tanner Stage 4
Breast: areola and papilla form a secondary mound (“double scoop”)
Pubic hair: adult type hair covering the pubes but not extending to the medial thighs
Female Tanner Stage 5
Breast: adult breast contour, projection of the papilla only
Pubic hair: adult type hair extends onto the medial thighs
Male Tanner Stage 1
Genitalia: pre-pubertal
Pubic hair: pre-pubertal, no hair or villus hair only
Male Tanner Stage 2
Genitalia: thinning and reddening of the scrotum, enlargement of the testes
Pubic hair: scant amount of downy, straight hair along the labia
Male Tanner Stage 3
Genitalia: penis increase in length, continued enlargement of the testes
Pubic hair: darker, coarser, curly hair that spreads sparsely across the central region
Male Tanner Stage 4
Genitalia: penis increases in breadth, development of the glans, continued enlargement of the testes
Pubic hair: adult type hair covering the pubs but not extending to the medial thighs
Male Tanner Stage 5
Genitalia: adult male genitalia
Pubic hair: adult type hair extends onto the medial thighs
Is constitutional growth delay a concern?
No, they are just “late bloomers” and will catch up
When there is a concern for growth hormone deficiency, what is the believed causative agent and organ?
Deficiency in growth hormone releasing factor is the believe causative agent
The hypothalamus is the affecting organ
Clinical findings:
Short stature
Increased subcutaneous adiposity
Hypoglycemia
Microphallus (boys)
Delayed bone age
Child-like face with a prominent forehead
High-pitched voice
Slow growth velocity
Growth hormone deficiency
If you have a patient with GH < 10mg/mL after two stimulation tests of <18mg/mL on a combined arginine-GHRH stimulation test, what is the next step?
Refer to pediatric endocrinologist for management of GHD
What is the most common cause of growth hormone excess?
Pituitary adenoma
Pre-epiphyseal fusion GHE symptoms
Sudden increase in growth velocity resulting i extreme height
Post-epiphyseal fusion GHE symptoms
Acromegaly, coarse facial features, protruding jaw, large hands/feet, thickened skin
Gonadarche onset 9.5 y/o
Pubarche before 8 y/o
Thelarche before 7 y/o
Menarche before 10 y/o
Precocious puberty
No breast development by 13 y/o
Menarche >5 yrs from thelarche
Menarche > 16 y/o
No testicular enlargement by 14 y/o
> 5 yrs between gonadarche and Tanner St. 5
Delayed puberty
What is the most common cause of hypothyroidism in adolescents?
Hashimoto’s
When is congenital hypothyroidism normally detected?
Newborn screening
If a patient presents with hyperthyroidism, when will it normally appear in children?
11-15 y/o
What is the most common clinical finding of hyperthyroidism in children?
Behavioral disturbances
Is surgery recommended to hyperthyroid management in children?
No, first line treatment is anti-thyroid medications in children with surgery reserved for adult management
When trying to differentiate between T1 and T2 diabetes, what can be drawn to help determine the underlying pathology?
GAD antibodies
When educating parents on re-hydrating their child to prevent dehydration, what is an important aspect to include?
The use of electrolyte containing drinks such as pedialyte as using water only can cause water intoxication if they child has also lost significant electrolytes.
Chronic inflammatory disease w/ exacerbation and remissions anywhere in the intestines
Crohn’s disease
Clinical findings:
Diarrhea
Rectal bleeding
Abdominal pain
Growth failure
Malnutrition
Pubertal delay
Bone demineralization
Crohn’s disease
Who manages Crohn’s disease primarily for the child?
Pediatric GI
Recurring bloody diarrhea w/ acute and chronic inflammation limited to the colon and rectum with associated weight loss d/t chronic caloric insufficiency
Ulcerative colitis
Clinical findings:
Fever
Weight loss w/ anorexia
Delayed growth or puberty
Arthritis/arthralgia of large joints
Diarrhea w/ or w/o frank blood and mucus
Lower ab cramping, LLQ pain, pain w/ stooling, tenderness on palpation
Oral ulcers
Skin lesions
UC
Do children always have ulcers or erosions noted with UC?
No, this is normally a later sign and is the reason many kids are often mis-diagnosed with Crohn’s
What dietary changes are appropriate for patient’s with UC?
High protein, high carbohydrate, decreased fiber
Avoid lactose (poorly tolerated)
Vitamin and iron supplements (poor absorption)
Which organism is the biggest causative agent for acute diarrhea?
Rotavirus
Clinical findings:
Anorexia
Low-grade fever
Watery, bloodless diarrhea
Vomiting
Abdominal cramping
Dehydration
Weight loss
Rotavirus
When considering differentials for acute diarrhea, what are diagnostic testing used to help narrow down the differentials?
Stool exam (if available sample)
Stool pH
Occult test
Stool ova and parasite, WBC w/ culture
Rotavirus antigen w/ ELISA
One or more liquid to semi-liquid stool per day for >14 days
Chronic diarrhea
Besides the acute diarrhea testing, what testing would be added for chronic diarrhea to help narrow differentials?
Sweat chloride test
Lactose intolerance testing
UA w/ C&S
What is the most common parasitic infection of the GI tract in the US?
Giardia lambia
Mountain water source
Municipal water and food sources
Contaminated well water
Fecal-oral route of transmission
Associated: ab cramping, flatulence, watery/greasy stools
+ stool culture
Giardia
Peri-rectal itching, worse at night
Pinworms (enterbius vermicularis)
How do you treat pinworms?
Mebendazole (Vermox)
Clinical findings:
Bloating
Flatulence
Abdominal cramping
Loose, watery diarrhea (15 min- 2 hours after consumption of the product)
Abdominal distention
Pain increased with palpation
Borborygmi
Lactose intolerance
Clinical findings:
Atopic dermatitis
Urticaria
Angioedema (rare)
Rhinitis
Asthma
Anaphylaxis (rare)
Chronic diarrhea, weight loss, FTT
Milk allergy
Autoimmune disorder with genetic predisposition affecting small intestine leading to flattening of the small intestinal mucosa
Celiac Disease
What conditions is there a higher co-morbid prevalence of Celiac with?
Down Syndrome, Turner Syndrome, Type 1 Diabetes
Is a UA diagnostic for UTI/Pyelo?
No, it only helps to raise or lower suspicion. Urine Culture is diagnostic
Do you treat asymptomatic bacteriuria?
If there is no leukocytes on a UA, there is no treatment
What are the antibiotics for UTI treatment?
Bactrim, Amoxicillin, cephalosporins, cipro (if PNC and ceph allergy)
When do you repeat a urine culture on a patient with a UTI or pyelo?
In 48-72 if symptoms persist to check for abx resistance
Regurgitation of urine from the bladder into the ureters and potentially up to the kidneys
Vesicoureteral reflux (VUR)
PMH UTI, abnormal voiding pattern, unexplained febrile illness, chronic constipation, UTI symptoms are all RF for?
VUR
In patients with VUR, what is the treatment management?
Treat underlying comorbid condition
Interval urine cultures
Prophylactic abx
Refer to Nephro
Your patient is brought in by mom for noted red urine with voiding. You obtain a sample today and dipstick the urine. It comes back with > +1 hematuria and +1 protein. What is your next step?
Refer to nephro
When would you consider referring a patient for a renal biopsy?
Gross hematuria
If your patient has asymptomatic hematuria, when would you re-evaulate?
Every 1-2 years
Clinical findings:
Edema (periorbital)
Low urine production
GI symptoms
Anorexia
Irritability, fatigue
Muscle wasting, malnutrition, growth failure
HTN
Chronically ill-appearing
Nephrotic syndrome
Genetic disorder causing excessive excretion of protein in the urine from increased GFR
Nephrotic syndrome
What diagnostic testing is indicated for nephrotic syndrome?
UA, urine protein, CBC, BMP, Lipid panel, C3/C4 complement, ANA, karotyping can be considered
What is the management for nephrotic syndrome?
Control edema
Refer to nephrology
Hospital if severe symptoms
Noninfectious, inflammatory response of the kidneys
Nephritis
Classic form of glomerulonephritis
Poststreptococcal GN
Clinical findings:
Strep skin or pharyngeal infection in past 2-3 weeks
Abrupt onset of gross hematuria
Decreased urine output
Lethargy, anorexia, N/V, chills, fever, backache
Transient HTN
Edema, circulatory congestion
Ear malformations
Flank/abdominal pain
CV angle tenderness
Rash/arthralgia
Nephritis/GN
What is the management for PSGN?
Supportive care (normally will spontaneously remit)
Severe oliguria/HTN-> admit
Abx if positive cultures
Does IgA nephropathy have a good outcome?
No, it has a poor outcome d/t the autoantibodies
Dysfunction of the renal tubule transport capability leading to low serum CO2
Renal tubular acidosis
Clinical findings:
Failure to gain weight
Polyuria/polydipsia
Muscle weakness
Irritability before/satiation after eating
Preference for liquids
Arrested growth curve after the 1st year
Renal tubular acidosis
How is renal tubular acidosis treated?
Oral alkalizing medications to correct acid/base balance
What is the most common GI tumor malignancy?
Wilms tumor
Clinical findings:
Age 2-5 y/o
Palpable mass
Increased abdominal size
Pain with rapid growth
Hemorrhage
Possible L varicocele if spermatic vein obstructed
Wilm’s Tumor
Can a child with a Wilms tumor play sports before or after treatment?
Yes, but they need a kidney protector and should avoid high impact sports
Can a male child with hypospadias be circumcsized?
It is not recommended, they should instead by referred to pedi urology
When should you refer a patient with cryptorchidism (undescended testes)?
Prior to 6 months for best outcomes with surgical intervention ideally around 9-15 months
Is there specific treatment for a hydrocele?
No, it generally resolves spontaneously. If the fluid continues to fluctuate in a communicating hydrocele for > 1 yr, can refer to urology
Clinical findings:
Swelling in the inguinal area/scrotum
Premature child, weight-lifter, obesity
Transillumination doesn’t occur
Silk glove sign
Inguinal hernia
What is the management for an inguinal hernia?
Attempt to reduce
Refer to urology for reduction, these do not spontaneously resolve
Are testicular masses normally malignant?
Yes, they are almost always malignant and require prompt referral to oncology
If a patient has a paraphimosis that you cannot reduce, what is the next step?
ED immediately as this is a surgical emergency
Your patient presents with inflammation of the glans of the penis. They are fussy and a culture collected is positive for bacteria. What is the next step?
Antibiotics and warm soaks for comfort
What is the most common cause of scrotal trauma?
Sports
You happen to be rotating in the ED today. You have a 16 y/o M patient come to see you for sudden onset, L sided (unilateral) scrotal pain. He is ill-appearing and anxious. On exam you find ipsilateral scrotal erythema and edema with progressive L sided swelling, redness, and warmth. When examining him, his testis are exquisitely painful and transillumination reveals a solid mass. He has no cremasteric reflex. What is your next step?
STAT page urology and obtain a STAT bedside US for concern of testicular torsion that is a medical emergency
Clinical finding:
Painful scrotal swelling
+ sexual activity
Dysuria, frequency
Fever, N/V
Scrotal edema/erythema
Epididymis hard, enlarged, and tender
Cremasteric reflex normal
Possible hydrocele, urethral discharge, prostate tenderness
Epididymitis
What is the common causative agent of epididymitis?
Gonorrhea or Trich
What is the management for epididymitis?
Symptom management
Ceftriaxone and doxycycline (together)
Treat sexual partners
“Blue dot” sign is positive in what diagnosis?
Torsion of the appendix testis
Hey you, yeah you
GO CRUSH THIS TEST!
