Exam 3 Flashcards
Differentiate between S&S of viral, allergic, and bacterial conjunctivitis
Viral: watery discharge, red, itchy conjunctiva, swollen eyelids, bilateral
Bacterial: Purulent discharge, always starts unilateral
Allergic: Severe itching, stringy, clear discharge, allergic shiners
Differentiate between treatment of viral, allergic, and bacterial conjunctivitis
Viral: warm or cool compresses, strict eye hygiene
Bacterial: topical antimicrobial (polytrim, cipro, tobramycin) x 5-7 days, warm compresses QID
Allergic: Prevention, saline solution, artifical tears, cool compresses, topical antihistamines (elestat), decongestants
What is the proper exam technique used to identify an eye abnormality in an infant or young child?
Red reflex (asymmetric)- dim lights, arms length from the head, inspection, fix and follow with each eye, corneal light reflex
What is strabismus? When is it concerning and need for further evaluation?
-Misalignment of eyes
-Refer if ocular misalignment is consistent after 4 months of age
What eye abnormalities are normal in the infant? What isn’t normal and would call for further evaluation?
-Poor visual acuity
-Variable alignment and exotropia which should resolve at 6 months of age
-Abnormal or asymmetric red reflex is abnormal- refer to ophthalmologist
What is an indication for prescribing antibiotics for a child with a respiratory infection?
-Only if suspecting bacterial cause (such as persisting > 10-14 days with high or worsening fever), most causes of URIs are viral
Differentiate between viral and bacterial respiratory infections
Bacterial: Symptoms will persist longer than expected 10-14 days, higher fever, fever gets worse
Viral: Self-limiting, improves in 10-14 days
Differentiate between the presentation of otitis media and otitis externa
Otitis Media: fever, pain, ear dsicharge, tugging at ear, crying, decreased appetitie, recent URI, unable to see normal landmarks on TM, hole in TM, TM red and bulging
Otitis Externa: recent hx of swimming or placing object in ear, painful to move tragus, redness around ear, decreased hearing
Differentiate between the treatment of otitis media and otitis externa
Otitis media: Abx, tylenol, amoxillin, cefdinir
-Otitis externa: supportive treatment with warm compress, NSAIDs, tylenol, possible prednisone
When is it ok to do “watchful waiting” with otitis media?
-If young child with unilateral AOM without severe symptoms (intense TM erythema, bulging TM) or fever; requires close follow up in 48-72 hours via clinic or phone call
Differentiate between viral and bacterial pharyngitis
Viral: cervical lymphadenopathy, may have fever rhinitis, cough, other systemic complaints more common than with bacterial
Bacterial: lack of cough or nasal symptoms, exudative, erythematous pharynx with a follicular pattern
When are antibiotics indicated for pharyngitis?
-If suspecting bacterial cause or if rapid-strep or throat culture is positive for GABHS (first choice is PCNs and if allergy do cephalexin/azithromycin)
How do you identify microcytic versus macrocytic anemia with CBC lab values? What is the significance of reticulocyte count?
Microcytic: Decreased MCV often with decreased MCH in iron-deficiency anemia
Macrocytic: Increased MCV
Reticulocyte count: Helps to distinguish disorders resulting from hemolysis or bleeding from inability to produce RBCs
What is a common cause of B12 deficiency?
-If diet lacks B12 (vegan or vetetarian diets) or if the gastric intrinsic factor necessary for absorption is absent
What is a common cause of sickle cell disease?
Genetics- autosomal recessive disorder that primarily affects people of African descent
What are common causes of iron-deficiency anemia?
LBW, rapid growth, blood loss, inadequate dietary intake, lead poisoning, early weaning to cow’s milk before one year, excessive intake of cow’s milk
What are the treatment options for different forms of anemia?
-Identify and treat cause: Folic acid, vitamin B12, iron supplements, referral to pediatric hematology, transfusion if needed
What is a common cause of thalassemia?
Cause is hereditary- autosomal recessive gene that causes microcytic anemia
What additional labs would you ordered if CBC results show iron deficiency anemia?
Ferritin, total iron-binding capacity (TIBC)
Treatment for iron-deficiency anemia
Iron (ferrous sulfate) supplements and iron-rich foods: beans, red meat, green leafy vegetables
How long do capillary hemangiomas take to resolve?
-At about 1 year of age, the hemangioma slowly starts to shrink and fade in color; often many completely go away by 10 years of age
Using the step-wise asthma treatment approach: when would you want to escalate or deescalate treatment?
Escalate: If benefit or improvement of symptoms is not observed within 4-6 weeks and patient’s medication technique and adherence are satisfactory
De-escalate: gradually if asthma is well-controlled for 3 months
How long should you continue treatment at each step for step-wise asthma treatment plan?
-When a child is well-controlled for 3 months, the provider can gradually step-down the treatment regiment (ICS can be decreased 25-50% every 3 months to the lowest dose possible)
What age group is bronchiolitis typically found in?
Infacy- 2 years with common causative agent RSV
Describe S&S of bronchiolitis
-URI symptoms for 3-7 days
-Gradual respiratory distress
-Bronchial spasms
-Increased RR
-Crackles/wheezing
What is the difference between croup & bronchiolitis?
Croup: Acute onset at night with harsh, barking cough and inspiratory stridor with swelling/erythema of lateral walls of the trachea
Bronchiolitis: URI symptoms for 3-7 days with gradual respiratory distress, bronchial spasms, crackles, and wheezing
S&S/Dx for pneumonia in children
S&S: Abrupt high fever if bacterial, restlessness, chills, SOB, chest pain, cough
DX: CXR shows consolidation of alveolar space
What age of child should you send to the ED when you expect a diagnosis of pneumonia?
-If less than 4 months old should immediately be hospitalized
What are the criteria for hospital admission for a child diagnosed with pneumonia?
-Comorbidities, family can’t monitor closely, increased respiratory rate (> 50 BPM if older child or > 70 if infant), Ox < 92%, grunting, retractions, poor feeding
How do you identify innocent versus pathologic murmurs?
-Pathologic: radiation, diastolic, grade >IV, interferes with S1 and S2, increases with sitting/standing, unequal femoral & radial pulses
-Innocent: Midsystolic, no radiation, does not interfere with S1, S2, decreases with sitting/standing, equal pulses, normal H&P
Describe the common types of cardiac murmurs in children
Innocent:
-Stills: Midsystolic, louder when supine or with inspiration
-Pulmonary flow: Short, early systolic to midsystolic, decreases when standing
-Venuous hum: Constant swishing sound
How would you identify pediatric hypertension?
-Elevated BP on at least 3 separate occasions
What are the risk factors for pediatric hypertension?
-Family Hx
-Obesity
-Sodium intake
-Hx of kidney disease
-Murmur, cardiac history
-Meds: amphetamines, steroids
What is the treatment for pediatric hypertension?
-Tx underlying cause
-Lifestyle modifications- exercise, decreased sodium
-Referral to cardiology/nephrology
-Medications (hydralazine)
A child presents to the clinic with hypertension, and 3+ protein on UA. What labs/diagnostic tests should you order? What referrals should be immediately made (2)?
-CBC, ESR, CRP, UA, CMP, ECHO, referral to a nephrologist and/or cardiologist
Diagnosis of pertussis
-Prolonged cough with characteristic whooping sound on inspiration
What is the treatment for pertusiss?
Macrolides: erythromycin, azithromycin, clarithromycin
Isolation instructions for a child diagnosed with chickenpox
Stay away from pregnant women, immunocompromised, and unvaccinated neonates; keep out of daycares/schools until all lesions are crusted over
What is a potential complication of untreated scarlet fever?
Rheumatic fever/ heart valve disease
What are the most common symptoms associated with Tetralogy of Fallot diagnosis?
Cyanosis, hypoxia, delayed growth, metabolic acidosis, exercise intolerance, finger clubbing, systolic murmur at L intercostal spaces and holosystolic murmur at left sternal border
What are the four anatomic abnormalities associated with Tetralogy of Fallot
-Pulmonary valve stenosis
-Overriding aorta
-VSD
-Right ventricular hypertrophy
Differentiate between the presentations for ventricular septal defect, atrial septal defect, and patent ductus arteriosus
ASD: Murmur at left sternal border, split heart sounds, CHF, delayed growth, fatigue
VSD: Dyspnea, tachypnea, pulmonary disease, holosystolic murmur at left lower sternal border
PDA: Continuous systolic murmur under L. clavicle referring to back, pulmonic thrill, bounding pulse
Diagnosis & treatment for eczema (atopic dermatitis)
Dx: most common symptom is pruritis; can start at early age, high serum IgE; rash is papulovesicular with lichenification and excoriations
Tx: avoid harsh soaps, antihistamines, low potency corticosteroids (short term), abx if secondary infection
S&S and treatment for Chickenpox (varicella)
-S&S: vesicular/umbilicated rash that starts on torso/scalp and spreads peripherally, URI Sx, HA
-Tx: Avoid scratching, benadryl, IV acyclovir if severe or immunocompromised
S&S of Kawasaki’s disease
-Fever > 5 days
-4/5 of these features: changes in extremities (edema, erythema), polymorphous exanthem, conjunctival injection, erythema and/or fissuring of lips & oral cavity( strawberry tongue), cervical lymphadenopathy
Diagnosis and treatment for meningococcal disease
-S&S: fever, headache, myalgia, flu-like sx, septic shock, stiff/painful neck, petechial rash
-Dx: Blood/CSF/sputum cultures
-Tx IV ABX & hospitilizations
Treatment for Acne in the neonate
-Watchful waiting
-Gentle daily cleansing with soap and water
Diagnosis and treatment for Hand, Foot & Mouth disease
S&S: Sore throat, malaise, possible lymphadenopathy, oral lesions, ulcers with red halos, lesions to hands and feet that start as red/flat/macular and become white with a red halo
Tx: Supportive- tylenol, warm baths, magic mouthwash
What education should be provided with diagnosis fo Hand, Foot, & Mouth disease?
Self-limiting: should resolve in 7 days, VERY contagious (2 days before & 2 days after eruption)
Treatment for HSV
-PO Acyclovir 20-40 mg/kg/day for 5 days
-Topical aycyclovir 5% 5x/day
S&S of HSV
Pain, malaise, drooling, swollen glands, fever, grouped vesicles w/ erythematous base, lymphadenopathy, yellow/white plates on mucosa
S&S of roseola
-Affects young children 6-36 months old
-Abrupt high fever followed by rash (white patches around red spots) that starts on neck and trunk and spreads to face and extremities
Primary S&S of Lyme disease?
-Erythema migrans rash around site of bite and Bulls eye lesion following
-Rash is warm and itchy but not painful
-Possible flu-like symptoms
Tx for Lyme disease
-< 8 years old = amoxicillin 50 mg/kg/day TID for 14 days
>8 yrs old = Doxycycline 200 mg daily or 4mg/kg BID for 14 days
What is the golden standard diagnostic test for rocky mountain spotted fever?
IFA (Indirect immunofluorescence antibody)
What is the treatment for rocky mountain spotted fever?
Doxycycline (start within 5 days of symptoms)
Name and describe some symptoms of measles (rubeola)?
Coryza- increased mucous and inflammation of mucous membrane in the nose
Kolpik spots- white/gray patches inside the mouth
What is the treatment for measles?
Vitamin A/Supportive care
Describe the distinct phases of symptom presentation in fifth disease
1- facial redness for 4 days
2- Lacey rash 2 days after facial redness
3- Fever, itching, petechiae
Definitions for RDW (CBC lab value)
RBC distribution width: size & shape of RBCs
Definition of MCV (mean corpuscular volume)
Average size of RBCs
Definition of MCH (mean corpuscular hemoglobin)
Average amount of Hgb in an RBC
What would elevated neutrophils on a WBC with diff lab indicate? Decreased?
-Elevated- infection, inflammation, tissue damage, leukemia
-Decreased: viral condition, overwhelming infection that exhausts bone marrow
Which aspects of the WBC with diff would indicate an allergic reaction?
Elevated eosinophils or basophils
Follow up for patient with iron-deficiency anemia
1 month for repeat exam and CBC; continue iron therapy for 2 months after anemia is resolved
S&S of sickle cell anemia
-Labs: HCT 18-22, elevated reticulocyte count
-Pallor, jaundice, splenomegaly, pain, stroke
Treatment for sickle cell anemia
-Evaluate for precipitating factors
-Adequate hydration
-Adequate pain control
S&S of impetigo
-Pruritic “honey crust” rash with vesicles that release yellow drainaage
What is the treatment and education for imptetigo?
Tx: topical mupirocin/bactroban, bacitracin, cephalexin, erythromycin
Education: Wash face BID, no school for 24-48 hours
First-line treatment for acne vulgaris
Topical treatment: Benzoyl peroxide, tretinoin
S&S of tinea capitis
Red, dry patch that spreads to red raised border with central clearing; loss of hair
Tx for tinea capitis
PO griseofulvin microsize (if > 2 yrs); take with high fat meal
Topical antifungal shampoo: ketoconazole
Treatment and education for lice
Tx: Permethrin 1% cream, pyrethrin 33% shampoo, delouse & nit removal with comb
Education: Assess all family members and close contact friends, wash everything, soak combs and brushes
Tx of Kawasaki’s disease
IV immunoglobulin, ASA, echo with cardiology consult—> ER referral
When should a child be referred for ear tubes?
> 3 confirmed ear infections in 6 months or 4+ episodes in 12 months with tympanic membrane rupture
Treatment for AOM with existing tubes
-Topical medications: Ciprofloxacin/Ciprodex or Fluroquinolones (do not use neomycin if TM perforated)
What are the major differences between Kawasaki and Scarlet fever?
Kawasaki- Viral, not contagious; most common in children <5yo; can cause heart rhythm problems; strawberry tongue, high fever for many days; treatment: IgG
Scarlet fever- Bacterial, most common 5-15 yrs, can cause cardiac and kidney complications, S&S- bright red rash, strawberry tongue, Tx: Amoxicillin or zithromax
What is an important consideration after giving IgG for treatment of Kawasaki?
Wait to vaccinate for chickenpox or measles at least 11 months after a IgG infusion because if can affect how the vaccines work
What is ophthalmia neonatorum and what is the most common cause?
Conjunctivitis in the newborn; chlamydia
Describe management for sinusitis
-Meds: Augmentin, azithromycin, or bactrim DS for 10 days
-Decongestants, antihistamines, saline rinses, nasal steriods
Describe management for epistaxis
-Sit upright and lean forward
-Pressure to nares at boney structure for 10 minutes
-Packing/topical vasocontrictor
-Air humidifier in room, petroleum jelly in nares, identify possible causes
When should a patient with suspected pharyngitis NOT be examined by the provider?
If the patient is drooling, has stridor, or trouble breathing
How would you treat a mono and concurrent strep infection?
Erythromycin due to likeliness of PCNs causing a rash
S&S of infectious mononucleosis
Fever, exudative pharyngitis, posterior cervical adenopathy
S&S of peritonsillar abscess
-Starts as acute febrile URI or pharyngitis and suddenly gets worse
-Fever, anorexia, drooling, dyspnea, unilateral swelling of one tonsil, displaced uvula
Management for peritonsillar abscess
-Asipration of abscess
-CT head/neck
-MNTR airway
-Emergent ENT consult
Recommendations for dental care
-Start fluoride with first tooth eruption
-Brush teeth BID for 2 minutes
-See dentist by 1st birthday or 6 months after first tooth erupts
Management for suspected pathologic murmur in children
-Refer to cardiology
-ECHO
-No sports until W/U is complete
Which pediatric ENT diagnosis is a potential emergency and what are the S&S?
Epiglottitis: Do not inspect pharynx or lay patient supine
-S&S: Sudden onset fever, severe sore throat, hoarse voice, drooling, tripod position, stridor, thumbprint sign
What is a common cause of epiglottitis?
HIB
How do you diagnose cystic fibrosis?
-Clinical features and laboratory findings: GI or nutritional problems, metabolic alkalosis. chronic sinopulmonary disease; must have at least one of: + sweat test, genetic analysis CFTR mutation, elevated glycosylate Hgb in older children
Typical CBC profile for IDA
-Microcytic, hypochromic
-Low MCV, normal or low RBC
-High RDW, low ferritin, high TIBC
Define intermittent asthma (step 1)
-Symptoms less than 2 times per week
-No interference with normal activity
-Nighttime symptoms two times or less per month
-FEV > 80% predicted
Diagnostics for asthma
-PFTs: gold standard
-Peak flow measurements
-CXR
Normal HR for infants and children
Newborn: 100-180
1 wk-3 mo: 100-220
3 mo-2 yrs: 80-150
2yrs-10yrs: 70-100
S&S of scarlet fever
Lace-like rash that starts on the torso and spreads to armpits, groin, strawberry tongue with red cheeks
Case assessment: 3-yr-old presents to clinic and mom states she has had a rash on bilateral lower extremities starting 2 days ago. Rash has been spreading and is described as red dots. Denies pain/itching. What additional questions would you ask?
-Any new medications?
-Any recent illnesses?
Case assessment: 3-yr-old presents to clinic and mom states she has had a rash on bilateral lower extremities starting 2 days ago. Rash has been spreading and is described as red dots. Denies pain/itching. What is the most likely diagnosis?
Thrombocytopenia purpura likely due to a viral illness or strep throat
Case assessment: 3-yr-old presents to clinic and mom states she has had a rash on bilateral lower extremities starting 2 days ago. Rash has been spreading and is described as red dots. Denies pain/itching. What is the DDX?
-Hemophilia: Genetic, x-linked; women can carry gene but only affects males
-Von-Wildebran’s: Genetic
-Leukemias: Big, blotchy rash
What would you suspect if a patient’s CBC and Ferritin shows the following: low MCV, low MCHC, normal ferritin?
Thalassemia
