Exam 2: Lectures Flashcards by Becca Sopelak

-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

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-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

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-Inflammation of nasal epithelium d/t release of chemical mediators from antigen-antibody reactions

Allergic rhinitis

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Clinical findings:
-rhinorrhea
-nasal pruritus
-congestion
-sneezing

Allergic rhinitis

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Allergic rhinitis management

Avoid triggers
Oral or intranasal antihistamines
Intranasal corticosteroids
Leukotriene inhibitors
Immunotherapy (allergy shots) for severe symptoms not responsive to other methods

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-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

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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

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Management of atopic dermatitis:

Cotton clothing
Hydrate skin (emollients, ointments)
Pharmacologic anti-itch medication
Topical low-potency corticosteroids (high-potency will dry skin further)

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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)

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+Rheumatoid factor and ANA are present in what type of JRA?

Polyarticular

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Oligoarticular
Polyarticular
Systemic
Enthesitis

4 types of JRA

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Management of JRA

Refer to rheumatology and PT
NSAIDs, oral corticosteroids can help with inflammation

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-Chronic systemic autoimmune disorder
-ANA production and multi-organ system involvement

Systemic lupus erythematosus (SLE)

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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

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+ANA in 97% of children with this disorder

SLE

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Management of SLE:

-Refer to pediatric rheumatology
-Will need pain management

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Clinical findings:
-Myofascial pain
-Fatigue
-Trigger points on PE
-Vague and/or variable multi-organ involvement

Fibromyalgia syndrome

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Diagnostic criteria:
-3 months or longer
-Hx of pain
-11-18 trigger points
-Exclusion of other disease processes

Fibromyalgia syndrome

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Management of fibromyalgia syndrome:

PT
Therapy
NSAIDs

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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)

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Management for CFS

Psychologic support
Exercise

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Autoimmune inflammatory process triggered as a complication of Group A Strep
Diagnosed based on Jones criteria

Acute Rheumatic Fever

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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

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Systematic vasculitis in kids
Dx with clinical findings
Etiology is unknown

Henoch-Scholein Purpura (HSP)

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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?

1. ELISA, if positive then, 2. 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?

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

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!