Exam 4 Flashcards
S&S of appendicitis
-Awakens at night with vague periumbilical pain
-Pain worsens over 4 hours
-Pain eventually migrates to RLQ and is worsened with movement
-Anorexia
-Vomiting
-Diarrhea
-McBurney’s sign, Rovsing’s sign, psoas sign, obturator sign
-Involuntary guarding
Diagnostic tests for appendicitis
-Rovsing’s: pressure in LLA elicits pain in RLQ, Psoas, Obturator, rebound tenderness (Bloomberg’s sign)
-CBC: may or may not have elevated WBCs, will have shift to the left w/ increased neurophils/bands
-US, CT with contrast (highest accuracy)
Describe the obturator and psoas signs to assess for appendicitis
Obturator- Flex the right leg, rotate the hip internally while patient is supine; positive if this illicits pain
Psoas- patient lies supine or on left side and flexes right hip (lifts leg) against pressure from the examiner- positive if this causes pain
What are the different types of knee injuries?
-Osteochondritis dissecans- bone or cartilage separates from the rest of the bone due to stress or trauma
-Patellar dislocation-patellar malalignment
-ACL sprain- acute injury from twisting or hyperextension
-MCL sprains- most commonly injured due to valgus (inward) stress to an extended knee
-Meniscal tear- significant injury, uncommon in youth <12 years of age
-Quadriceps contusion- bruising of quadriceps muscle, often from sports injury
How do you diagnose different types of knee injuries?
-Valgus/Varus stress: checks lateral amd medial collateral ligaments
-McMurray test for meniscus cartilage tear
-Lachman test (ACL injury)
-X-ray, CT, MRI (ligament or meniscus tear)
What are some exam techniques for diagnosing knee injury? Examples of a few are Lachman and McMurray tests
-Valgus/Varus stress: examiner holds knee joint and ankle joint and moves knee from side to side
-McMurray: examiner grasps supine patient’s heel and knee, knee is maximally flexed and rotated internally (lateral meniscus) and externally (medial meniscus)
-Lachman test- flex the knee to 20-30 degrees and attempt to pull tibia anterior to femur
What is the first line treatment for UTIs in children?
-Bactrim 8-10mg/kg/day
-If younger than 3 months old: amoxicillin or augmentin
-Keflex and other cephalosporins (Cefdinir) good for E. Coli
How would a UTI presentation differ for different ages such as toddler versus school-aged children?
Infants: FTT, diarrhea, jaundice, polyuria, malodorous urine
Children < 2 years: fever, vomiting, anorexia, FTT
-Children 2-5 yrs: fever, abdominal pain
-School-aged: Classic signs such as dysuria, frequency, urgency, CVA tenderness
Describe diagnosis and management of hydrocele
-Dx: Transillumination (pink or red), unilateral edema, asymmetry, non-communicating (blue-tinged) or communication (fluid comes and goes)
-Management: Refer to urology if persists after 1 year
Describe diagnosis and management of hypospadias
-Dx: Physical exam shows dorsally hooded foreskin in newborn
-Management: Referral to urologist, surgery
What is the difference between a muscle sprain and strain?
-Sprain- Injury to the ligaments and capsule at a joint or the body. Graded 1-3 with 3 being a complete ligament tear
-Strain- an injury to muscles or tendons
S&S of Legg-Calves-Perthes disease
-Unilateral hip or thigh pain that can radiate to the knee
-Painless limp
-Limp worsens after activity
-Reduced ROM of hip
-NSAIDS often don’t help with pain
Diagnostic criteria for Legg-Calves-Perthes disease
-X-ray: AP & frog leg lateral will shows flattening and fragmentation of the femoral head
-MRI may show osteonecrosis
S&S of slipped capital femoral epiphysis
-Limping, knee and/or hip pain
-Pain worse with activity
-May be unable to bear weight
-Loss of internal rotation with flexion
-Affected extremity may be shorter
-Loss of abduction & extension
Diagnostics & Management for slipped capital femoral epiphysis
Dx. X-ray shows widening of the epiphysial line and displacement of the femoral head
Mngmnt: Referral for ortho, non-weight bearing until surgical eval
How do you diagnose scoliosis?
-Forward bend test (Adam’s): patient leans forward with his or her feet together and ben 90 degree at the waist
-Other PE findings: shoulders are different heights, uneven waste, dimples or color changes over spine, leaning of body to one side
-X-ray: standing, full length posteroanterior and lateral views of spine- evaluates Cobb angle
What is the treatment for diarrhea in children?
-Rehydration
-Pre/Probiotics
How would you evaluate a child for dehydration?
-Sunken anterior fontanel
-Tachycardia, decreased cap refill
-Decreased UOP (ask about wet diapers)
-Increased urine specific gravity
-Decreased BP is late finding (severe)
-Evaluate mucous membranes
S&S of pyloric stenosis
-Regurgitation during first few weeks of life
-Projectile emesis begins at 2-3 weeks of life
-Constantly hungry
-Weight loss
-Dehydration
-Constipation
-Emesis may contain blood
S&S of intussusception
-Most common cause of intestinal obstruction < 2 years of age, more common in boys
-Screaming and drawing up of legs with periods of rest
-Stool with blood
-Sausage-like mass may be felt in RLQ (Dance’s sign)**
-Abdominal distention and tenderness
Diagnostics & management for intussusception
-Abdominal US
-Consult pediatric surgeon
-Air contrast enema is diagnostic and usually curative
-Risk of recurrence in 24 hours
S&S of Hirschprung’s disease
-Failure to pass meconium in first 48 hours of life
-FTT, constipation, abdominal distention, diarrhea, vomiting
How much percentage of body weight loss occurs in dehydration?
Mild: up to 5% in infants and 3% in children
Severe: 10-15% in infants, 9% in children
What are common bacterial causes of dehydration in children?
E. coli, salmonella, shigella
What is the difference between type I and type II diabetes?
-Type I: Requires insulin and is resulted from immune mediated beta cell destruction; most common in children and adolescents
-Type II- may respond to lifestyle changes and oral medications; results from pancreatic beta cells being unable to produce enough insulin
What are the pre-prandial and post-prandial glucose goals for DMI and DMII?
-Children < 6 years: avoid low blood sugars and keep glucose 100-200 mg/dL
-Children 7-12: Pre-prandial goal of 80-180 mg/dL
-Adolescents: 70-150 mg/dL
What exam findings would make you expect a growth hormone deficiency and how would you further evaluate it?
-Features: Short, slow growth, childlike face with prominent forehead
-Dx: CBC, sed rate, UA, Growth factors (IGF-1 and IGFBP-3), TSH, free t4
What is premature adrenarche? What are the S&S?
-Early onset of pubic or axillary hair in boys or girls not associated with true puberty
-S&S: Taller than expected, DHEA levels elevated, increased pubic hair without other signs of puberty such as breast growth
What are the common findings with hyperthyroidism?
Palpitations, tremor, increased appetitie, weight loss, fatigue, muscle weakness, poor sleep, Goiter, thyroid bruit, tachycardia
What are the risk factors for DMII in children and adolescents?
Overweight, Family Hx, high-risk ethnicity (hispanic, AA), inadequate exercise
What are the common causes of delayed puberty?
-Delayed 13 years or older in girls and 14 years or older in boys
-Anorexia, chronic anemia, chronic renal failure, respiratory or cardiac disease, endocrine disease, hypothyroidism, growth hormone deficiency
What is precocious puberty? What are the S&S?
-Early onset of puberty before 8 years of age in girls and 9-10 in boys
-S&S: Increased pubic hair, early menstruation, body odor, acne, height increases rapidly but stops at an early age
Methods for prevention and identification of mental illness in children and adolescents
-Screening tools provided in clinic such as the GAD-7 and PHQ-9
-Identify children at risk related to family home and history, background, life circumstances
-Discuss with parents need for predictable home and routines, stable childcare, healthy relationships, freedom from discrimination
What is the first line medication for depression in children?
SSRIs (except paroxetine b/c of increased risk for suicide); Sertraline approved for children greater than 6
Diagnostic criteria for depression
-5 or more symptoms (nearly every day) have been present during the same 2 wk period and representing a change in function
-Must have one of: depressed mood, marked diminished interest or pleasure, significant weight loss when not dieting, weight gain or decrease in appetite
Important concept of treatment for a child with depression
-SAFETY!
-Determine suicide risk or likeliness to harm self or others, determine risk for ongoing abuse or neglect if returning to same home
What age can you start using the PHQ-9 assessment tool?
11 yrs
Most common somatic complaints in children with depression
HA & stomachache
If a child has separation anxiety as a small child, what sequelae can that lead to when they become an older adolescent or adult?
Panic disorder and depression
What is the most common pediatric anxiety disorder?
Separation anxiety
Describe the different types of headaches
-Migraine: N/V, unilateral, pulsating, relief with sleep, aura, visual changes, family Hx
-Tension: Pain is dull & bifrontal or occipital; can last for days to weeks
-Secondary (due to tumor or something leading to increased ICP)- pain worse in AM, vomiting w/o nausea, occipital and neck pain, edema of the optic disc
When is separation anxiety considered normal?
From about 7 months old through preschool years
Describe management for the different types of headaches
-CT if suspecting tumor
-NSAIDS
-Prophylaxis: CCB, tricyclic antidepressants
-NO TRIPTANS in children
-Reduce caffeine intake
-Increase fluids
SNOOP pneumonic to identify red flags for headache
-Systemic symptoms or disease
-Neurologic signs or symptoms
-Onset sudden
-Onset before age 5 or after age 50
-Pattern changes from prior headaches
How do you evaluate for ADHD? What are the criteria for diagnosis?
-Symptoms (> 6 mo) that occur in at least 2 or more settings, evidence of impairment in social, academic, or occupational areas
-At least 6 inattention symptoms and 6 hyperactivity/impulsivity symptoms
-Some Sx must be present before 7 years
Name some treatments for ADHD? What is the common age range of onset?
-First line: behavioral modifications: CBT, parenting, family support, career planning, school folders
-Drugs (in order of preference): psychostimulants, alternate psychostimulant, pemoline, antidepressants, clonidine
Age: 8 years
Describe evaluation and treatment for febrile seizures
-Assess for focal abnormalities, seizure activity, signs of head trauma
-Obtain blood glucose and lumbar puncture if less than 2 months old
-Reduce fever and provide education related to seizures
Why are newborns jaundiced?
-Newborns have a high number of red blood cells in their blood, which are broken down and replaced frequently
-a newborn’s liver is also not fully developed
-Poor dietary intake
-Should resolve within 2 weeks of birth
Treatment for infant jaundice
-Calculate risks for bilirubin induced neurotoxicity
-Continue breastfeeding
-Phototherapy with bili light or bili blanket
-F/U next day for bilirubin re-test
Describe the different kinds of jaundice in the infant
Physiologic- Normal, resolves within 2 weeks after birth
Breastfed-induced- D/t poor dietary intake (not necessarily FTT)
Biliary atresia- Would also note poor weight gain, elevated LFTs, and abnormal liver ultrasound showing fibrosis of portal vein
-Liver failure- FTT, inflammation of liver
When would fluoroquinolones be indicated for treatment in a child?
ONLY if complicated UTI or pyelonephritis
What is Osgood Schlatter disease?
-Pain and lump at the tibial tuberosity/knee caused by repetitive pulling of the patellar tendon against the growth plate; common later in childhood and early adolescence
Describe the rule of threes in the diagnosis of colic in infants
-Healthy infant cries > 3 hours per day
-> 3 days per week
- > 3 weeks
Management for colic
-No cure
-Simethicone can help to ease parents minds
-Often resolves by 3 months of age
Education for infants with GERD/frequent spitting up
Self-limiting: fades at about 6 months with sphincter maturity
What are some red flags with GERD to look out for?
-Bilious vomiting
-GI bleeding
-Forceful vomiting
-FTT
-Feeding problems
Management for GERD in infants
-Smaller, more frequent feeds
-Thickened formula with cereal
-Breastfeeding is still OK
LIfestyle modifications for older children with GERD
-Weight loss
-Avoid chocolate, caffeine, high fats, spicy foods, alcohol
-Left lateral decubitus sleeping position with elevation of HOB
What is the most common cause of abdominal surgery in children?
Appendicitis
What are S&S of celiac disease?
Diarrhea, short stature, iron-deficiency anemia, lactose intolerance, irritability, itchy skin rash with blisters, irritable bowels
Lab tests for celiac disease
Transglutaminase antibody, biopsy of small intestine would show villous blunting
S&S of Crohn’s disease
Fever, weight loss, delayed growth, arthralgias, anorexia, diarrhea, oral ulcers, perianal skin tags or fistulas
Diagnostic tests for Crohn’s
-ESR, CRP, CBC, Liver, Total bili, stool tests, EGD and colonoscopy
What are three basic causes of failure to thrive?
-Inadequate caloric intake
-Inadequate caloric absorption
-Excessive caloric expenditure
What are some alarm signs and symptoms with constipation?
-Constipation < 1 mo old
-Passage of meconium > 48 hours
-Ribbon stools
-Blood in stools
-Failure to thrive
-Fever
-Bilious vomiting
-Sacral dimple
What is encopresis?
Fecal incontinence after child should be able to control BM
When should a child with acute diarrhea be evaluated?
If persists for 72 hours or more or is associated with blood in stool
What is the diagnostics and treatment for Giardia (the most common parasitic infection in US)?
-Dx: 3 cultures over 1 week
-Furazolidone 5 to 8 mg/kg in 4 divided doses for 7-10 days
When should an infant with an umbilical hernia go to the ED?
-If swollen or discolored, not reducible, or if causing emesis
Management for an umbilical hernia
-Most are harmless and should resolve by age 5
Define a complicated UTI
Fever, toxicity, dehydration, child < 6 months, UTI with structural abnormality
What labs should be ordered if you suspect pyelonephritis?
CBC, ESR, BUN, Creatinine
Most common physical exam finding with varicocele
“Bag of worms”
Which male GU diagnosis is a medical emergency?
Testicular torsion
S&S of testicular torsion
-Acute onset unilateral pain
-Hx of trauma
-N/V
-Swelling, redness, warmth in scrotum
-Absent cremasteric reflex
DDx for gross hematuria
Glomerulonephritis, renal disease, UTI, trauma, coagulopathy, crystalluria, nephrolithiasis, rhabdomyosarcoma
Criteria for diagnosis of diabetes
-Symptoms of DM plus random glucose > 200 mg/dL ~OR~
-Fasting glucose > or equal to 126 mg/dL ~OR~
-2 hour plasma glucose > or equal to 200 mg/dL during OGTT
Describe the “CHUMS” pneumonic for Type I DM education
C: Carbodhydrate counting
H: Hypoglycemia treatment
U: Urine ketones
M: Monitor blood glucose
S: Shots
Who should be screened for DMII?
-Children over 10 years or in puberty who’s BMI is > 85% or >120% ideal for height
~AND~ Have two of the following risk factors: Family Hx, Race: Native american, AA, Hispanic, pacific islander, Signs of insulin resistance such as acanthosis nigricans, PCOS, HTN, dyslipidemia
Dx for precocious puberty
-Hormone levels
-X-rays of hand and wrist
-US of pelvis and adrenal glands
-CT/MRI of brain to look for tumors hypothalamus and pituitary glands
When would adolescent growth spurts be in relation to puberty for girls and boys? When is the growth spurt considered over?
Girls: Tanner stage 2
Boys: Tanner stage 3
Over: Tanner stage 5
Genu varum versus genu valgus
Genu varum: bowlegs or outward turn of knee; normal physiological alignment at birth and often corrects on its own
Genu valgus: knock knee; refer if persistent after 6 years for surgical repair
What 3 HPI/PE findings would make you suspect Legg-Calve-Perthes?
-Age 2-10 years and gender male
-Proximal thigh pain and limp
Wheat would you suspect if an adolescent patient presents with proximal thigh pain and limp?
Slipped capital femoral epiphysis (SCFE) or overuse
What congenital musculoskeletal diagnosis are more common in females?
Hip dysplasia and scoliosis (abnormal curvature progresses more than in males, requiring intervention)
Treatment for Osgood-Schlatter
-RICE
-Quad and hamstring stretching
-NSAIDS
-Self-limiting and will get better over time
Management for Legg-Calve-Perthes
-Referral to orthopedic
-Observation if < 6 years old who maintain 40-45 degree abduction
-Surgery
Risk factors for SCFE
-Obesity
-Male
-Sports
-Femoral retroversion
-Hypothyoridism
-Average age: 12 yrs for girls, 13 for boys
-Bilateral in 50%
Risk factors for hip dysplasia
-Female
-Breech presentation
-First born
-Common in whites & Native Americans
When and how do you assess for hip dysplasia in clinic?
-At each well child visit until walking
-PE: assymmetric skin folds, reduced abduction, unequal leg length, hip exam on firm surface with Ortolani meanuver and Barlow maneuver
S&S of clubfoot
Foot is in a pointed toe position, sole of the foot is inverted, forefoot has convex shape, increased arch and heel is turned inward
Tx for clubfoot
-Xray to measure degree of misalignment
-Orthopedic referral for serial castings weekly and nightly brace or surgical intervention
What could consistent toe walking that persists past 6 months indicate?
-Neurological problem
-Autism
-Tight heal cords
-Muscular dystrophy
When is surgery indicated for scoliosis? When is a brace indicated?
-Brace: after 25 degrees of curvature
-Surgery: >40 degrees of curvature
S&S of brachial plexus injury
-Lack of use of affected arm
-Absent bicep and Moro reflex
-Absent grasp reflex
-Rupture of intra abdominal structures liver/spleen
-Fracture of skull, clavicle, or humerus
-Limited neck movement
Screening tools for ADHD
-Vanderbilt scale- filled out by teacher and parents (2 different settings)
-Connor rating scales
What are the two main stimulants used for treatment of ADHD? Describe side effects
-Methylphenidate and amphetamine/dextroamphetamine
-Anorexia, insomnia, can increase tics
Max medication doses for ADHD stimulants
-2 mg/kg/day for Methylphenidate and 1mg/kg/day for amphetamines
Management for Legg-Calve-Perthes
-Referral to orthopedic
-Observation if < 6 years old who maintain 40-45 degree abduction
-Surgery
When is surgery indicated for scoliosis? When is a brace indicated?
-Brace: after 25 degrees of curvature
-Surgery: >40 degrees of curvature
Screening tools for ADHD
-Vanderbilt scale- filled out by teacher and parents (2 different settings)
-Connor rating scales
What are the two main stimulants used for treatment of ADHD? Describe side effects
-Methylphenidate and amphetamine/dextroamphetamine
-Anorexia, insomnia, can increase tics
ADHD follow up
-Phone F/U 1 week
-See in clinic 1 month after starting therapy to ensure stable and no weight loss
-Visit every 3-4 months
-
Autism is characterized by problems in what 3 areas?
Communication, behavior, and social skills
Autism occurs more often in which gender?
Males
What is the gold standard for assessing and diagnosing autism?
The Autism Diagnostic Observation Schedule (ADOS)
General S&S of autism
-Lack of awareness of others
-Avoids eye contact
-Unable to engage in cooperative play
-Speech problems
-May use screaming and tantrums as a way to communicate
-Distress over changes in the environment
Treatment for Bell’s Palsy
-Often has spontaneous remission and recovery in 1-9 weeks
-May need ocular lubricant if eyelid is affected
-PO steroids- controversial
-Acyclovir if herpetic cause
Treatment for Guillain-Barre
-Hospitalization for IVIG for 5 days
-Follow up with rehab, PT, OT, speech
Interventions for abnormal head growth and cranial abnormalities in infants and children
-CT scan, monitor development
-Referral to pediatric neurologist
8-yr-old patient reports to the clinic with emesis, dehydration, fatigue, frequent voiding, and constant thirst. UA shows ketones and glucose and blood sugar is 220. What is the diagnosis?
DMI due to signs of ketoacidosis and pre-pubertal onset
15-yr-old M presents for sports physical. He reports left knee pain with extension, jumping, and running. Pain is mild to moderate and only with movement. Noted occasional swelling. PE noted to have tenderness of palpation of patella, negative drawers, tenderness at tibial tuberosity. What is the most likely diagnosis?
Osgood-Schlatter- common in adolescents
What is the most common children musculoskeletal injury?
Ankle injury
