MTB Paed Flashcards
Red eye at day 1, day1-7, day >7
- At 1 day, the most likely cause of the conjunctivitis is chemical irritation.
- From days 2 to 7, the most likely cause is Neisseria gonorrhoeae.
- Conjunctivitis after more than 7 days post delivery is most likely due to Chlamydia trachomatis.
- Conjunctivitis after 3 weeks or more is most likely due to herpes infection.
Normal Vital Signs in a Newborn
Respiratory rate (RR) of 40 to 60 breaths per minute (BrPM) Heart rate (HR) of 120 to 160 beats per minute (BPM)
Ophthalmia neonatorum prevention
All newborns require eye drops
Erythromycin and silver nitrate
Most Commonly Tested Disorders in Newborns
- G6PD deficiency: X-linked recessive disease characterized by hemolytic crises. Treatment involves reducing oxidative stress and specialized diets.
- Phenylketonuria (PKU}: autosomal recessive genetic disorder character-ized by a deficiency in the enzyme phenylalanine hydroxylase (PAH) that leads to mental retardation. Treatment is with a special diet low in phenyl-alanine for at least the first 16 years of the patient’s life.
- Galactosemia: a rare genetic disorder that precludes normal metabolism of galactose. Treatment is to cut out all lactose-containing products.
- Congenital adrenal hyperplasia: any of several autosomal recessive diseases resulting in errors in steroidogenesis. Treatment is to replace mineralocorticoids and glucocorticoid deficiencies and possible genital reconstructive surgery.
- Congenital hypothyroidism: a condition affecting 1 in 4,000 infants that can result in cretinism.
- Hearing test: excludes congenital sensory-neural hearing loss. Necessary for early detection to maintain speech patterns and assess the need for cochlear implantation.
- Cystic fibrosis: autosomal disorder causing abnormally thick mucus. Best initial test: Sweat chloride. Most accurate test: Genetic analysis of the CFTR gene. Classic findings on the USMLE: Combination of an elevated sweat chloride, presence of mutations in CFTR gene, and/or abnormal functioning in at least one organ system.
Transient Conditions of the Newborn
Polycythemia
Tachypnea
Hyperbilirubinemia
Duchenne-Erb Paralysis: Cs-C6
- “Waiter’s tip” appearance; secondary to shoulder dystocia
- The infant is unable to abduct the shoulder or externally rotate and supinate the arm.
Diagnosis is made clinically and immobilization is the best treatment.
Klumpke Paralysis: C7-C8+/- T1
- “Claw hand” due to a lack of grasp reflex
- Paralyzed hand with Horner syndrome (ptosis, miosis, and anhydrosis)
Diagnosis is made clinically and immobilization is the best treatment.
Most common abdo mass in children
Wilms tumor
The most common cancers in infancy and the most common extracranial solid malignancy.
Neuroblastoma
Neuroblastoma is an adrenal medulla tumor similar to a pheochromocytoma but with fewer cardiac manifestations. The percentage of cases presenting with metastases ranges from 50% to 60%. Look for two highly tested findings:
Hydrocele
Hydrocele is a painless, swollen fluid-filled sac along the spermatic cords within the scrotum that transilluminates upon inspection.
- Remnant of tunica vaginalis
- Usually will resolve within 6 months
- Must differentiate from inguinal hernia
Varicocele
Varicocele is a varicose vein in the scrotal veins causing swelling of pampini-form plexus and increased pressure. The most common complaint is dull ache and heaviness in the scrotum
Cryptorchidism
Cryptorchidism is an absence of one testicle in the scrotum, and is usually found within the inguinal canal.
- Ninety percent of cases can be felt in the inguinal canal.
- Orchipexy is indicated to bring the testicle down into the scrotum after the age of 1 to avoid sterility.
Hypospadias
With hypospadias, the opening of the urethra is found on the ventral surface of the penis.
- High association with cryptorchidism and inguinal hernias
- Needs surgical correction
- Circumcision contraindicated due to difficulties in surgical correction of the hypospadias
Epispadias I
With epispadias, the opening to the urethra is found on the dorsal surface.
- High association with urinary incontinence
- Must evaluate for concomitant bladder exstrophy
- Needs surgical correction
Reflexes
- Sucking reflex: Baby will automatically suck on a nipplelike object.
- Grasping reflex
- Babinski reflex: toe extension
- Rooting reflex: If you touch a baby’s cheek, the baby will turn to that side.
- Moro reflex: Arms spread symmetrically when the baby is scared.
- Stepping reflex: walking-like maneuvers when toes touch the ground
- Superman reflex: When held facing the floor, arms go out.
Tetralogy of fallot
Definition and presentation
- Overriding aorta
- Pulmonary stenosis
- Right ventricular hypertrophy
- Ventricular septal defect (VSD)
- Cyanosis of the lips and extremities
- Holosystolic murmur best heard at the left lower sternal border
- Squatting after exercise activities (spells)
VSDs are common in
Down (trisomy 21), Edwards (trisomy 1 8), and Patau (trisomy 13).
Cynosis during and after neonate period
Tetralogy of Fallot is the most common cyanotic condition in children after the neonatal period.
Transposition of the great vessels (TOGV) is the most common cyanotic lesion during the neonatal period.
Pulsus alternans:
sign of left ventricular systolic dysfunction
Pulsus bigeminus:
sign of hypertrophic obstructive cardiomyopathy (HOCM)
Pulsus bisferiens:
in aortic regurgitation
Pulsus tardus et parvus:
aortic stenosis
Pulsus paradoxus:
cardiac tamponade and tension pneumothorax
Irregularly irregular:
atrial fibrillation
Eisenmenger syndrome (ES).
ES is defined as the process in which a left-to-right shur1’t caused by a VSD reverses into a right-to-left shunt due to hypertrophy of the right ventricle.
3 major types of ASD:
- Primum defect: concomitant mitral valve abnormalities
- Secundum defect: most common and located in the center of the atrial septum
- Sinus venosus defect: least common
PDA presentation and treatment
- “Machinery”-like murmur with • Wide pulse pressure
- Bounding pulses
- A high occurrence of respiratory infections and infective endocarditis is the most common complication later in the child’s life.
Give prostaglandins to pop open a PDA.
Give indomethacin to inhibit popping.
Cardiac X-ray findings
Cardiac X-Ray Findings
• Pear-shaped: pericardial effusion
• Boot-shaped heart: tetralogy of Fallot
• Jug handle appearance: primary pulmonary artery hypertension
• “3”-like appearance or rib notching: coarctation of the aorta
Long QT syndrome Dx
a combination of hearing loss, syncope, normal vitals and exam, and family history of sudden cardiac death is all you need to clinch the diagnosis
a short girl with webbed neck, shield chest, streak gonads, horseshoe kidneys, or shortened fourth metacarpal, think…
coarctation of the aorta.
Pathological jaundice
Jaundice on the first day
Direct bilirubin
Causes kernicterus (basal ganglia) Hypotonia, Seizure, hearing loss
Check ABO and Rh compatibility
vomiting with first feeding” or choking/ coughing and cyanosis
Tracheoesophageal fistula
90% Oesophageal atresia is associated with TEF
Projectile vomiting and palpable abdominal mass
Pyloric stenosis
String sign, olive sign
1 month
Coanal atresia
Blue with feeding
Pink when crying
CHARGE syndrome is a set of congenital defects seen in conjunction.
C: coloboma of the eye, central nervous system anomalies
H: heart defects
A: atresia of the choanae
R: retardation of growth and/or development
G: genital and/or urinary defects (hypogonadism)
E: ear anomalies and/or deafness
Hirschsprung Disease
Hirschsprung disease is a congenital lack of innervation of the distal bowel by the Auerbach plexus.
Hirschsprung do not pass meconium for over 48 hours or fail to pass meconium at all. • Extreme constipation is followed by large bowel obstruction. • Rectal exam shows an extremely tight sphincter; an inability to pass flatus is also common.
VACTERL syndrome.
V: vertebral anomalies A: anal atresia C: cardiovascular anomalies T: tracheoesophageal fistula E: esophageal atresia I R: renal anomalies L: limb anomalies
bilious vomiting within 12 hours of birth.
Duodenal atresia
colicky abdominal pain, bilious vomiting, and currant jelly stool
Intussusception
painless rectal bleeding. Massive frank bright red blood per rectum
Meckel’s diverticulum
Necrotizing enterocolitis presentation
Child born severely premature with low birth weight
• Vomiting and abdominal distension
• Fever
Congenital adrenal hyperplasia
- Fluid and electrolyte replacement along with lifelong steroids to maintain adequate levels of mineralo/glucocorticoid levels
- Specific psychiatric counseling to aid with gender identity issues
TORCH
T: toxoplasmosis 0: other infections such as Syphilis R: rubella C: cytomegalovirus H: herpes simplex virus
Viral childhood infection
Varicella Varicella zoster Rubeola measles Fifth disease or erythema infectiosum Roseola Mumps
Scarlet fever presentation
Scarlet fever presents with a classic pentad of (1) fever, (2) pharyngitis, (3) sand-paper rash over trunk and extremities, (4) strawberry tongue, and (5) cervical lympadenopathy.
Croup
Croup presents with barking cough, coryza, and inspiratory stridor.
Steeple sign
Whooping cough Dx and treatment
Diagnostic Tests
• Clinically made diagnosis with whooping inspiration, vomiting, and burst blood vessels in eyes
• “Butterfly pattern” on chest x-ray
• PCR of nasal secretions or Bordetella pertussis toxin ELISA
Treatment
• Erythromycin or azithromycin aids only in the catarrhal stage, not in the paroxysmal stage.
• Isolate the child, and macrolides must be given for all close contacts.
• DTaP vaccine has decreased incidence.
Once the child is delivered,
the mouth and nose are suctioned, followed by clamping and cutting of the umbilical cord. The newborn is then dried, wrapped in clean towels, and placed under a warmer as he has just descended from an environ- ment of 98.6° Fto approximately 65° F.
Normal Vital Signs in a Newborn
Respiratory rate (RR) of40 to 60 breaths per minute (BrPM) Heart rate (HR) of 120 to 160 beats per minute (BPM)
As the neonate’s colonic flora has not adequately colonized, E. coli is not present in sufficient quantities to make enough
vitamin K to produce clotting factors II, VII, IX, and X and proteins C and S.
Elevated AFP levels indicate both
neural tube defects and abdominal wall defects.
Reflexes
- Sucking reflex: Baby will automatically suck on a nipplelike object.
- Graspingreflex
- Babinski reflex: toe extension
- Rootingreflex:Ifyoutouchababy’scheek,thebabywillturntothatside.
- Moro reflex: Arms spread symmetrically when the baby is scared.
- Stepping reflex: walking-like maneuvers when toes touch the ground
- Superman reflex: When held facing the floor, arms go out.
The history of exercise intolerance and squatting while playing outside (tet spells) is pathognomonic for
tetralogy of Fallot.
Cyanosisofthelipsandextremities
•Holosystolicmurmurbestheardattheleftlowersternalborder
• Squattingafterexertiveactivities
PDA is a normal finding in the first
12 hours of life. After 24 hours it is considered pathologic.
Give indomethacin (NSAID inhibits prostaglandins) to close the PDA unless it is needed to live in concurrent conditions such as TOF.
Give prostaglandins to pop open a PDA.
Kernicterus presents with
hypotonia, seizures, choreoathetosis, and hearing loss.
Inflammatory diarrhea will have
fever, abdominal pain, and possible bloody diarrhea.
Noninflammatorydiarrheawillhave
vomiting,crampyabdominalpain, and watery diarrhea.
When there is confirmed evidence of necrotizing enterocolitis, start antibi- otics; Necrotizing enterocolitis (NE) is a condition seen in premature infants where the bowel undergoes necrosis and bacteria invade the intestinal wall. The con- dition carries a mortality of up to 30%.
the antibiotics of choice are vancomycin, gentamicin, and metronidazole.
Scarlet fever is a
diffuse erythematous eruption that is concurrent with phar- yngitis. It is caused by erythrogenic toxin made by Streptococcus pyogenes and typically lasts 3 to 6 days.
1) fever, (2) pharyngitis, (3) sand- paper rash over trunk and extremities, (4) strawberry tongue, and (5) cervical lympadenopathy.
Croup cause
It is most commonly caused by parainfluenza virus types 1 and 2. Respiratory syncytial virus (RSV) is the second most common cause.
Epiglottitis is a
severe, life-threatening swelling ofthe epiglottis and arytenoids due to haemophilus influenza type B. "Hotpotato"voice • Fever • Droolinginthetripodposition • Refusal to lie flat
