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PANCE Practice > PANCE Prep- Inpatient Pediatrics Pearls > Flashcards

PANCE Prep- Inpatient Pediatrics Pearls Flashcards

1
Q

Normal urine output

A

1.0-2.0 cc/kg/hour

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2
Q

Describe fluid requirements calculations

A

100/50/20 rule
-100 cc/kg/day for first 10kgs;
-from 10 to 20 kg, additional 50 cc/kg/day;
-over 20 kg, 20 cc/kg/day for each additional kg.
-Divide total daily fluid by 24
to get cc/hr.

Example: 8 kg patient-> 8 x 100 = 800 cc/day = 33 cc/hr
13 kg patient -> (10 x 100) + (3 x 50) = 1150 cc/day= 48 cc/hr

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3
Q

Describe fluid requirement calculations on an hourly rate

A

4/2/1 rule (to calculate hourly rate)

  • 4 cc/kg/hour for first 10 kg;
  • from 10-20 kg, additional 2 cc/kg/hour;
  • over 20 kg, give 1cc/kg/hour for each additional kg.

Example: 8 kg patient -> 8 x 4 = 32 cc/hr
23 kg patient -> (10 x 4) + (10 x 2) + (3 x 1) = 63 cc/hr

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4
Q

Describe caloric requirements

A
  • for patients < 10kg, 100-120 kcal/kg/day (ill or premature infants may have increased caloric need)
  • for older patients who are taking the majority of their calories as solid foods, we do not generally calculate caloric intake, unless a calorie count is being done.
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5
Q

Describe the calories found in breast milk

A

20kcal/ounce = 20kcal/30 cc = 0.67 kcal/cc

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6
Q

What are types of cow milk based formulas

A
  1. Similac

2. Enfamil Premature

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7
Q

What are types of soy based formula

A
  1. Isomil

2. Prosobee

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8
Q

What are types of Elemental based formulas

A
  1. Pregestimil
  2. Nutramigen
  3. Tolerex
  4. Vivonex
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9
Q

What are types of Premature infant formulas

A
  1. Special Care

2. Enfamil Premature

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10
Q

What is a lactose free formula

A
  1. Lactofree
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11
Q

Describe the weight loss and gain of an infant

A
  1. Infants should regain their birth weight by 10-14 days of age (after losing up to 10% of birth weight).
  2. Infant gains 1 ounce (30 grams) per day.
  3. Weight doubles by 5 months,
  4. triples by 1 year,
  5. quadruples by 2 years.
  6. Length doubles by 1 year,
  7. triples by 13 years.
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12
Q

Common microbes that cause UTIs

A

Gram Neg. Rods

  1. E. coli
  2. Pseudomonas
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13
Q

Common microbes that cause GI diseases

A

Anaerobes

  1. C. Diff
  2. Bacteroides fragillis
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14
Q

Common microbes that cause Skin, Pneumonia, AOM

A

Gram Positive Cocci

  1. S. pneumoniae
  2. S. pyogenes (GAS)
  3. MSSA
  4. MRSA

GN Cocci
5. N. gonorrhoeae

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15
Q

What is bronchioloitis

A

inflammation of the bronchioles due to neutrophil infiltration
-MC in children 2 month-2 y/o after viral infections (RSV and adenovirus)

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16
Q

persistent alveolar exudates–> inflammation and scarring (FIBROSIS) of the bronchioles AND alveoli

A

Cryptogenic Organizing Pneumonia (COP)– previously called BOOP (bronchiolitis obliterans with organizing pneumonia)
*looks like pneumonia but doesn’t respond to antibiotics

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17
Q

Most common cause of bronchioloitis

A

RSV (50-70%)

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18
Q

Risk factors for broncholitis

A
  1. 2months-2y/o
  2. exposure to cig smoke
  3. lack of breastfeeding
  4. premature (<37wks)
  5. MC in fall and spring**
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19
Q

Associated Complications of bronchiolitis

A
  1. Otitis media w/ S. pneumonia

2. asthma later in life

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20
Q

SX of bronchiolitis

A
  1. Fever
  2. URI sx 1-2 days
  3. THEN resp. distress (wheezing, tachypnea, nasal flaring, cyanosis, retractions +/- rales)
  4. poor feeding

*likely to deteriorate 48-72 hours after cough onset

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21
Q

How do you dx bronchiolitis

A
  1. CXR: hyperinflation, peribronchial cuffing
  2. nasal washing using monoclonal Ab testing
  3. Pulse ox single best predictor of disease in children***
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22
Q

Tx of bronchioloitis

A
  1. Supportive: humidified O2 (MAINSTAY OF TX) delivered by mask, IV fluids, acetaminophen/ibuprofen for fever, +/- mechanical ventilation if severe
    * *Nasal suctioning and hydration!
  2. Meds play a limited role***- +/- B agonists (albuterol), +/- nebulized racemic epi (if albuterol not effective)—– Corticosteroids NOT indicated unless hx of underlying reactive airway disease
  3. Ribavirin +/- administered if severe lug or heart disease or in immunosuppressed pt.
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23
Q

How can you prevent bronchioloitis

A
  1. Good hand washing- RSV is highly contagious and is transmitted via direct contact w/ secretions and self inoculation by contaminated hands
  2. Palivizumab prophylaxis may be used in high risk groups
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24
Q

What is the most sensitive indicator of LOWER airway disease

A

tachypnea

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25
Q

What is croup?

A

inflammation secondary to acute viral infection of the upper airway (vocal cords or trachea)–> subglottic larynx/trachea swelling
-MC in 6months-6y/o

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26
Q

What is the most common cause of croup?

A

Parainfluenza!

Others: adenovirus, RSV,

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27
Q

Signs of Croup

A
  1. Barking cough (seal-like)
  2. Stridor (inspiratory and expiratory worse w/ crying)
  3. hoarseness
  4. dyspnea (worse at night*)
  5. +/- other URI sx preceeding or concurrent
  6. fever
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28
Q

How do you dx croup

A
  1. R/O epiglottitis and FB aspiration
  2. CLINICAL DX
  3. CXR: steeple sign (subglottic narrowing of trachea)**
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29
Q

How to manage mild Croup

A
  1. Cool humidified air mist
  2. Hydration
  3. Dexamethosone oral or IM (provides sign. relief as early at 6hrs after single dose)
    * *1mg/kg/d for 3-5 days
  4. O2
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30
Q

How do you classify mild, mod, and severe croup

A

Mild: no stridor at rest, no resp. distress

Mod: stridor at rest w/ mild-mod retractions

Severe: stridor at rest w/ marked retractions

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31
Q

How to manage mod Croup

A
  1. Dexamethasone PO or IM
  2. supportive tx (humidified air, hydration)
  3. +/- Nebulized epi
  4. SHOULD OBSERVE 3-4hrs after intervention for rebound resp. distress
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32
Q

How to manage severe Croup

A
  1. Dexamethasone

2. Neb epi

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33
Q

What is whooping cough

A

highly contagious Brodetella pertussis infection

-MC in kids <2y/o

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34
Q

What are the pertussis phases

A
  1. Catarrhal phase: URI sx 1-2 weeks (MOST CONTAGIOUS IN THIS PHASE)
  2. Paroxysmal phase: severe paroxysmal coughing fits w/ inspiratory whooping, +/- post cough emesis: 2-4 wks
  3. Convalescent phase: resolution of cough (up to 6wks)
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35
Q

How do you dx pertussis (whooping cough)

A
  1. PCF of nasopharyngeal swab (gold standard)

2. lymphocytosis (60-80% lymphocytes of diff., WBC count elevated as high as 50,000

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36
Q

Tx of pertussis

A
  1. Supportive is mainstay
  2. O2 and nebulizers
  3. Abx- Macrolides, Erythomycin or Bactrim if allergic to macrolides
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37
Q

Complications of pertussis

A
  1. Pneumonia
  2. Encephalopathy
  3. otitis media
  4. sinusitis
  5. seizures
  6. apnea or cerebral hypoxia
  7. subconjuctival hemorrhage due to increased pressure from coughin
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38
Q

MC cause of CAP and what does its gram stain look like?

A
  • strep pneumoniae
  • Gram + cocci in pairs

(other common causes: H. influenza, Staph. Auerus, Morazella, kelbsiella)

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39
Q

MC cause of CAP in someone w/ underlying pulmonary disease* (COPD*, bronchiectasis, CF)

and what does its gram stain look like?

A

Haemophilus influenza
**2nd MC cause of CAP

also- M. catarrhalis

Gram neg. Rods (bacilli)

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40
Q

MC cause of atypical pneumonia or walking pneumonia and what does its gram stain look like?

A

Mycoplasma pneumoniae– eps. <40y/o

Lacks cell walls** (does not respond to beta lactams)

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41
Q

MC cause of pneumonia is school aged kids and what does its gram stain look like?

A

Mycoplasma pneumoniae
-and Chlamydophilia, and viral

Clinical: pharyngitis, ear infection, (BULLOUS MYRINGITIS) URI sx

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42
Q

MC cause of pneumonia due to water supply, air conditioners and what does its gram stain look like?

A

Legionella pneumonia

  • no person to person transmission
  • GI sx (N/V/anorexia, hyponatremia)

Intracellular GNR

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43
Q

MC cause of pneumonia often seen after viral illness (ie. flu) and what does its gram stain look like?

A

Staphylococcus aureus

Gram positive cocci in clusers

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44
Q

MC cause of pneumonia often seen in IVDU and what does its gram stain look like?

A

Staphylococcus aureus

Gram positive cocci in clusers

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45
Q

MC cause of pneumonia that causes severe illness in alcoholics and what does its gram stain look like?

A

Klebsiella pneumonia
(and other)
GNR (bacilli)

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46
Q

MC cause of pneumonia in debilitated, chronic illness, aspirators and what does its gram stain look like?

A

Klebsiella pneumonia

GNR (bacilli)

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47
Q

What pneumonia is associated w/

CXR: CAVITARY LESIONS

A

Klebsiella pneumonia

*esp. RUL

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48
Q

MC cause of ASPIRATION

A

Anaerobes ( in out pts- typically oral flora)

GNR in inpats or chronically ill

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49
Q

Aspiration pneumonias are MC found where

A

R lower lobe (anerobes)

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50
Q

MC cuase of pneumonia in immunocompromised (ie. HIV, neutropenic, s/p transplant, CF, bronchiectasis) and what does its gram stain look like?

A

Pseudomonas aeruginosa

GNR- produces slime coat

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51
Q

MC cause of hospital acquired pneumonia

A

GNR: pseudomonas

and MRSA

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52
Q

MC cause of pneumonia in infants and small children

A

viral- RSV and parainfluenza

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53
Q

MC cause of viral pneumonia in adults

A

Influenza

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54
Q

MC cause of viral pneumonia in transplant recipients or HIV

A

CMV

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55
Q

Who gets pneumocystis jirovecii pneumonia (PCP)

A

compromised host (fatigue, dry cough, dyspnea on exertion, O2 desat w/ ambulation)

*Fungal pneumonia

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56
Q

What fungal/parasitic pneumonia is associated w/ Mississippi and Ohio river Valley soil contaminated w/ Bird and bat droppings

A

Histoplasma capsulatum

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57
Q

Sx of typical pneumonia

A
  1. fever
  2. productive cough w/ purulent sputum
  3. RIGORS**- eps. S. pneumoniae
  4. tachycardia/tachypnea
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58
Q

Sx of atypical pneumonia

A
  1. Low grade fever

2. Extrapulmonary sx*- myalgias, malaise, HA, N/V/D

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59
Q

PE findings of typical pneumonia

A

Signs of consolidation:

  1. bronchial breath sounds
  2. dullness on percussion
  3. increased tactile fremitus, egophony
  4. crackles (insp)
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60
Q

PE findings of atypical pneumonia

A

*often normal

+/- crackles or rhonchi

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61
Q

What do you do/suspect if someone presents with:

ear pain, BULLOUS MYRINGITIS, red pharynx, persistent nonproductive cough

A

Mycoplasma PNA

-send serum cold agglutinins

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62
Q

Legionella pneumonia is associated with:

A
  1. GI sx
  2. Elevated LFTs
  3. Hyponatremia
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63
Q

What PNA is associated with:

CXR: abscess formation

A

S. aureus** (or Klebsiella, anaerobes)

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64
Q

What PNA is associated with Bullous myringitis

A

mycoplasma pneumonia

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65
Q 
PNA sputum (gram stain/culture) reveals:
Rusty, blood tinged
A

Strep pneumonia

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66
Q 
PNA sputum (gram stain/culture) reveals:
Currant jelly
A

Klebsiella

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67
Q

DX workup of pneumonia

A
  1. CXR (+/- CT scan)– CXR lags behind clinical improvement
  2. Sputum (gram stain/culture)
  3. PE- dull Percussion, INCREASED fremitus, bronchial, EGOPHONY breath sounds
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68
Q

What does percussion sound like in Pneumothorax or obstructive lung disease

A

HYPERRESONANCE

dull in pneumonia and pleural effusion

69
Q

Empiric Tx of CAP outpatient

A

Macrolide (Clarithromycin or Azithromycin) or doxycycline is first line***

70
Q

Empiric tx of CAP inpatient

A

B lactam + macrolide (or doxy) OR broad spectrum FQ

71
Q

Empiric tx of CAP in ICU

A

B lactam + macrolide

OR broad spectrum FQ + B lactam

72
Q

Empiric tx of hospital acquried pneumonia (pseudomonas infection risk)

A

Anti-pseudomonal B lactam and anti-pseudomonal AG or FQ

  • Add vancomycin if MRSA suspected
  • Add Levofloxacin or Azithromycin if Legionella is suspected
73
Q

What Abx do you add if you suspect legionella pna or MRSA pna

A

legionella: levofloxacin or azithromycin

MRSA: vancomycin

74
Q

B-lactam Abx used in PNA (CAP inpatient or ICU)

A

Cefriazone or Unasyn

75
Q

Anti-Pseudomonal B-lactams used in PNA (hospital acquired)

A

Pip/taz or Cefepime

76
Q

What are Respiratory fluoroquinolones (used in PNA- CAP Inpt, ICU)

A

Levofloxacin, Moxifloxacin

**Cipro is NOT A respiratory FQ

77
Q

What are aminoglycosides used in PNA (HAP)

A

Gentamicin, Tobramycin

78
Q

What Vx is used to prevent pneumonia

A

PCV13 (prevnar): given at 2, 4, 6 months, and 12-15 months

*those 2y/o-64 w/ chronic dz OR +65 y/o also get Pneumovax (PSV23)

79
Q

___ is the number 1 organism in pneumonia in children 3w-4y, ___ should be considered in 2-12w who are usually afebrile, __ cause a significant amount of pneumonia in children <5y, although up to 30% of these kids will have a ___ too
__ >5yo

A

S.Pneumo (3wks-4yo)

chlamydia (2-12 wks)

Viruses (<5yo)–> 30% have secondary bacterial infection

mycoplasma >5yo

80
Q

What PNA is associate w/:

CXR: peribronchial cuffing or interstitial infiltrates

A

viral pneumonia

81
Q

These CXR findings are commonly associated w/ what pneumonias:

  1. Lobar
  2. diffuse, patchy infiltrate, multi-lobar
  3. interstitial pattern
  4. cavitary lesions
A
  1. Lobar- Strep pneumo
  2. diffuse, patchy infiltrate, multi-lobar- S. aureus, H. influ
  3. interstitial pattern- Mycoplasma, legionella
  4. cavitary lesions- Klebsiella, pseudomonas, TB
82
Q

How do you tx Active TB infection

A 
RIPE
Rifamin (RIF)
Isoniazid (INH)
Pyrazinamide (PZA)
Ethambutol (EMB)
(OR Streptomycin instead of EMB)
  • tx for 6 months at least
  • no longer considered infectious 2wks after initiation of therapy
83
Q

What is asthma

A

REVERSIBLE hyperirritability of tracheobronchial tree–> airway inflammation and bronchoconstriction

84
Q

Describe the 3 main components (pathophysiology) of asthma

A
  1. Airway hyperreactivity- IgE mediated (extrinsic- allergen or intrinsic- viral infection, meds (BB, ASA, NSAID, ACEI), exercise, emotional)
  2. Bronchoconstriction/airway narrowing: SmM constriction, bronchial wall edema, mucus section
  3. Inflammation: secondary to cellular infiltrate, cytokines, and histamine
85
Q

Obstruction in bronchoconstriction is characterized by:

A
  1. decrease expiratory airflow
  2. increased airway resistance
    * V and Q mismatch
86
Q

What is Samters Triad

A
  1. Asthma
  2. Nasal polyps
  3. NSAID/ASA allergy
87
Q

Classic asthma triad of symptoms

A
  1. Dyspnea
  2. Wheezing
  3. Cough (esp. at night)

*if silent chest= no air exchange= severe!

88
Q

How can you dx asthma

A
  1. PFTs (Gold standard)
  2. Bronchoprovacation test (Methacholine challenge test)
  3. Peak Expiratory Flow rate (PEFR)
89
Q

PFTs of asthma will show

A
  1. Decreased FEV1

2. Decrease FEV1/FVC

90
Q

What is the best and most objective way to assess asthma exacerbation severity and patient response in ED

A

Peak expiratory flow rate (PEFR)– best to obtain baseline before tx

<40% = severe obstruction

PEFR> 15% from initial attempt = response to tx
-Normal 400-600

91
Q

Describe how you classify asthma

A

Rule of 2’s

  1. use of albuterol or rescue 2 or more times a week= Mild persistent
  2. Nocturnal Sx over 2x/month= Mod. persistent
  3. Sx all the time= severe persistent
  4. less than 2x week= intermittent asthma
92
Q

Describe PFTs of intermittent, mild, mod, and severe asthma

A
  1. intermittent: FEV1 >80% predicted, FEV1/FVC nl
  2. mild: FEV1 >80% predicted, FEV1/FVC nl
  3. mod: FEV1 60-80% predicted, FEV1/FVC reduced by 5%
  4. Severe: FEV1 <60% predicted, FEV1/FVC reduced by >5%
93
Q

Describe recommended management of intermittent, mild, mod, and severe asthma

A
  1. intermittent: SABA prn
  2. Mild: Saba prn + LD ICS
  3. Mod: SABA prn + LD ICS + LABA or Increase ICS to MD
  4. Severe: SABA prn + HD ICS + LABA +/- Omalizumab
94
Q

What is Omalizumab

A

anti-IgE Ab (inhibits IgE inflammation)

*used in severe, uncontrolled asthma

95
Q

Types of:

  1. SABA
  2. LABA
  3. ICA
  4. LT inhibitors
  5. Anticholinergics
A
  1. SABA: albuterol, terbutaline, epi
  2. LABA: Salmeterol, Formoterol
  3. ICA: Beclomethasone, Flunisolide, Triamcinolone
  4. LT inhibitors: Montelukast (singular)
  5. Anticholinergics: Ipratropium (atrovent)

*LABA/ICS combo: Symbicort, Advair diskus

96
Q

How to SABA and LABAs work?

A

B2 agonists

Bronchodilator, decrease bronchospasm

97
Q

Asthma drug of choice for long term persistent chronic management asthma

A

ICS

98
Q

When are leukotriene modifers helpful in tx of astham

A

asthmatics w/ allergic rhinitis/ASA inducted asthma

99
Q

SE of B2 agonists

A
  1. B1 cross reactivity: tachycardia/ arrhythmias, muscle tremors
  2. CNS stimulation
  3. hypokalemia
100
Q

Management of acute asthma exacerbation

A
  1. 2-4 puffs of SABA via MDI/spacer or neb
  2. Repeat x3 q 20 min
  3. Oral corticosteroids 2mg/kg/d
101
Q

Hospital evaluation for asthma exbaceration

A
  1. CXR (1st time wheezers, failure to improve w/ tx)
  2. PEFR pretx- <40% =severe
  3. ABS for sick pts PEFR <35%
  4. EKG if cardiac condition
102
Q

Tx of asthma exacerbation

A
  1. cardiac monitor (given 2ry tachycardia, HTN and palps)
  2. Pulse OX
  3. BP monitoring
  4. IV access if mod/severe
  5. B-agonist (albuterol) neb X3 (or 2-4 puffs)
    • Atrovent (ipratropium-anticholinergic)
      * continuous B2agonist for 1 hr if no better
  7. Steroids: 2mg/kg/d max at 60mg or 40-60mg for adults OR IV 125mg methylprednisolone
  8. +/- Magnesium sulfate, 1-2 mg IV
  9. +/- Heliox (80% helium, 20% Ox) - decreases airway resistance
  10. +/- intubate if increased PCO2, decreased PO2, AMS,
103
Q

Indications to discharge asthma pt

A
  1. feel better, not hypoxic, clear lungs
  2. PEFR >60%
  3. DC on B2 agonist, oral steroids 4-5 d.
  4. FU in 1-3 days with PCP
104
Q

how to interpret GFR and albumin

A

60+ = normal
below 60= kidney disease/poor functioning
below 15= failure

elevated albumin = kidney disease bc it is not being filtered out (should just be found in blood)

105
Q

Children receiving continuous albuterol nebulization are at risk of transient:

A
  1. hypokalemia,
  2. hypophosphatemia, and
  3. hypomagnesemia.

*Although these decreases are rarely of clinical importance in children, we suggest measuring serum electrolytes daily in all patients receiving continuous albuterol,

106
Q

Causes of Metabolic Acidosis with an Elevated Anion Gap

A

MUDPILERS (too much acid or little bicarb)

Methanol
Uremia
DKA/alcoholic KA
Propylene glycol
Isoniazid, infection
Lactic acidosis
Ethylene Glycol
Rhabdo/Renal failure
Salicylates
107
Q

Causes of Metabolic Acidosis with NO Anion Gap

A

HARDUPS (too much acid or little carb)

Hyperalimentation (artificial nutrients)
Acetazolamide
Renal tubular acidosis
Diarrhea
Uretero-Pelvic shunt
Post Hypocapnia
Spironolactone
108
Q

Causes of acute respiratory acidosis

A

CHAMPP *causes of hypoventilation

CNS depression (drugs/CVA)
Hemo/pneumothorax
Airway obstruction
Myopathy
Pneumonia
Pulmonary Edema
109
Q

Causes of metabolic alkalosis

A

CLEVER PD- little acid or too much bicarb

Contraction
Licorice
Endo (Cushings, Conn)
Vomiting
Excess Alkali
Post-hypercapnia
Diuretics
110
Q

Causes of respiratory alkalosis

A

CHAMPSS- causes of hyperventilation

CNS disease
Hypoxia
Anxiety
Mech ventilators
Progesterone
Salicylates
Sepsis
111
Q

Cellulitis is most commonly caused by what organisms

A

S. auerus*

Group A beta hemolytic streptococus (GABHS/S. pyogenes)

112
Q

LOCAL clinical manifestations of cellulitis

A

Macular erythema (flat margins, NOT sharply demarcated)

  • swelling
  • warmth
  • tenderness
113
Q

Special types of cellulitis

A
  1. Erysipelas: MC cause GABHS

2. Lymphangitis: spread of infection via lymphatic vessels

114
Q

Well demarcated margins of cellulitis, intensely erythematous (St. Anthony’s fire) most commonly on the face or skin w/ impaired lymphatic drainage

A

Erysipelas (mc cause GABHS)

115
Q

Tx of cellulitis

A

Cephalexin or dicloxacillin X 7-10 days
(Clindamycin or Erythromycin if PCN allergic)

  • If you suspect MRSA:
  • IV vancomycin or linezolid OR
  • Oral: Bactrim (2nd best PO for MRSA but doesn’t cover strep well)
116
Q

How do you tx cat bite cellulitis

A

Amoxicillin/clavulante

doxy if PCN allergic

117
Q

MC cause of cat bite cellulitis

A

Pasteurella multocida

118
Q

How do you tx dog bite cellulitis

A

Amoxicillin/clavulante

119
Q

How do you tx human bite cellulitis

A

Amoxicillin/clavulante

120
Q

How do you tx a wound through a tennis shoe? What organism must you cover for?

A

Ciprofloxacin (covers pseudomonas)

121
Q

MC cause of Osteomyelitis

A

S. aureus*

122
Q

salmonella osteomyelitis is pathognomonic for ___

A

sickle cell disease

123
Q

Sources of osteomyelitis

A
  1. Acute hematogenous spread: MC route in children

2. Direct inoculation: s/p trauma, surgery, prosthetic joint

124
Q

Clinical manifestations of osteomyelitis

A
  1. gradual onset of sx (days to weeks)- signs of bacteremia: high fever, chills, malise
  2. Local: inflammation, pain over bone, decrease ROM
  3. Refusal to weight bare
125
Q

Labs/Dx test for osteomyelitis

A
  1. increased WBC
  2. increased ESR (if ESR is normal, osteo. is unlikely)
  3. MRI (most sensitive test in early dz- CT for surgical planning)
  4. Bone aspiration: gold standard**
  5. Radiographs: shows bone infection but +/- up to 2 weeks after sx onset
    - early: soft tissue swelling and PERIOSTEAL REACTION, Lucent areas of cortical destruction
    - Advanced/chronic: SEQUESTRUM (segments of necrotic bone and new bone formation)
126
Q

TXof acute osteomyeltits

A

Abx 4-6 wks (at least 2 wks via IV) +/- debridement

127
Q

MC organism of newborn osteomyelitis

A

GBS, Gram neg.

128
Q

MC organism of osteomyelitis in someone older than 4 months

A

S. aureus

MSSA or MRSA

129
Q

MC organism of osteomyelitis from a puncture wound

A

Pseudomonas

130
Q

MC organism of osteomyelitis in someone w/ sickle cell dz

A

salmonella

131
Q

TX of osteomyelitis in someone older than 4 months

A

MSSA: Nafcillin or oxacillin or Cefazolin
(clindamycin or vancomycin if PCN allergy)

MRSA: Vancomycin

132
Q

TX of osteomyelitis in someone w/ sickle cell dz

A

3rd generation cephalosporin or FQ (Cipro* or levofloxacin)

133
Q

TX of osteomyelitis from a puncture wound

A

Ciprofloxacin (pseudomonas)

134
Q

XR: periosteal reaction of bone shaft

-w/ lucent areas of cortical destruction

A

Osteomyelitis

135
Q

What is the criteria for sepsis

A 
SOFA: infection + 2 or more:
(BAT)
1. sBP 100mmHg or less
2. AMS <15
3. Tachypnea (RR 22/min or greater)
136
Q

How can you assess for multiple organ dysfxn w/ sepsis

A 
CPKBNP
Cardiac/ MAP/vasopressors
Pulmonary
Kidneys: creatinine
Bilirubin
Neuro
Platelet count
137
Q

Risk factors for sepsis

A
  1. 65+
  2. ICU
  3. bacteremia
  4. immunocompromised/ asplenic
  5. prior hospitalization
  6. diabeteic
  7. PNA
138
Q

Work up of Sepsis

A
  1. CBC w/ diff
  2. CMP (hyperglycemia?)
  3. Lactate (>2?)
  4. Blood cultures x2
  5. Coags: PT, PTT
  6. ABGs
  7. UA?
  8. CXR: if pulm (also get sputum culture)
  9. CT if GI or menigitis
  10. LP
139
Q

Tx of sepsis

A

ABCs! (RESTORE PERFUSION AND GIVE ABX ~1HR OF PRESENTATION)

  1. 2 large bore IVs w/ fluid resuscitation
  2. Cardiac monitoring and VS q 15 min
  3. Abx: Vancomycin (G+ and MRSA coverage) + Cefepime (G-) +/- Pip/taz for pseudomonal coverage
  4. Acetaminophen for fever
140
Q

how can you assess nuchal rigidity

A
  1. Kernig sign: have the person lie flat on the back, flex the thigh so that it is at a right angle to the trunk, and completely extend the leg at the knee joint.
  2. Brudzinski’s sign: flex the pts neck and severe neck stiffness causes the patients his and neck to flex
141
Q

What is the workup for a fever of unknown source in a neonate 28 days or less?

A
  • nee full septic w/u if temp of 38C or 100.4
    1. CBC
    2. Blood cultures
    3. Gram stain
    4. UA
    5. Urine culture
    6. LP with CSF analysis and gram stain
    7. CSF culture
    8. +/- CXR if resp. sx: cough, rhinorrhea, tachypnea, WOB, abnormal breath sounds,
    9. +/- stool culture: if diarrhea

*Need IV abx

142
Q

Criteria for low risk for SBI in an infant 29 days +

A
  1. WBC between 5-15K (cannot be neutropenic)
  2. Bands not greater than 1.5 (cannot have leukocytosis)
  3. Band/neutrophil ratio of <0.2 (no left shift)
  4. U/A <10 wbc/hpf, negative gram stain
  5. CSF (if obtained) <8 wbc/hpf, negative gram stain
  6. CXR negative (if obtained)
  7. stool gram stain <5wbc/hpf (if obtained)
143
Q

What is the workup for a fever of unknown source in an infant 29-90 days old?

A
  • nee full septic w/u if temp of 38C or 100.4
    1. CBC
    2. Blood cultures
    3. Gram stain
    4. UA
    5. Urine culture
    6. LP with CSF analysis and gram stain
    7. CSF culture
    8. +/- CXR if resp. sx: cough, rhinorrhea, tachypnea, WOB, abnormal breath sounds,
    9. +/- stool culture: if diarrhea
144
Q

Tx if infant 29-90day old meet the low-risk criteria for SBI, consider

A

Ceftriaxone 50mg/kg IV/IM

145
Q

Work up for fever of unknown source in an infant 3-36 months

A
  1. 2 F
  2. UA
  3. urine gram stain
  4. Urine cultures: only for the select population of: girls <24 months, uncircumcised boys <12 months and circumcised boys <6 months
  5. A CXR, if indicated by symptoms or exam and a blood c/s based on risk of bacteremia
  6. blood cultures
146
Q

Use parenteral antibiotics for FWS awaiting cultures, preferrably ____

A

Ceftriaxone

147
Q

Causes of prolonged fever

A
  1. TB
  2. Lymphoma and Leukemia
  3. Juvenile Idiopathic Arthritis
  4. Endocarditis
  5. CMV, EBV
  6. Malaria
  7. Hyperthyroidism, Ectodermal dysplasia
  8. Kawasaki’s disease
148
Q

Symptoms of Kawasaki’s

A 
Crash and Burn
C-conjunctivitis
R- rash on body
A- arthritis (join pain)
S- strawberry tongue (red and swollen)
H- Hands skin peeling
AND
BURN- uncontrolled high fever persisting longer than 5 days
149
Q

Clinical manifestations of appendicitis

A
  1. anorexia
  2. periumbilical pain/epigastric pain
  3. RLQ pain
  4. N/V
150
Q

PE Signs specific for appendicitis

A
  1. Rovsing sign: RLQ pain w/ palpation
  2. Obturator sign: RLQ pain w/ internal and external hip rotation w/ flexed knee
  3. Psoas sign: RLQ pain w/ right hip flexion/extension (raise leg aginst resistance)
  4. McBurneys point tendernesss: 1/3 the distance from anterior sup. iliac spine and navel
151
Q

How do you dx appendicitis

A

CT
US
Leukocytosis**

152
Q

Risk factors for UTI

A
  1. sex
  2. spermicidal use
  3. pregnancy: progesterone and estrogen
  4. Vesicourethral reflux
  5. Newborns with fever of unknown origin
  6. DM
  7. catheters
  8. dysfunctional voiding
153
Q

Common cause of UTI

A
  1. E. coli (MC- 80%)
  2. Staph. saprophyticus: especially in sexually active women
  3. other GN uropathogens: proteus, enterobacter, klebsiella, pseudomonas
  4. Enterococci with indwelling cath
154
Q

Gram negative uropathogens

A
  1. E. coli
  2. proteus,
  3. enterobacter,
  4. klebsiella,
  5. pseudomonas
155
Q

Sx of pyelonephritis

A
  1. fever
  2. tachycardia
  3. flank/back pain
  4. CVA tenderness
  5. N/V
156
Q

How do you dx cystitis

A

UA w/

  1. pyuria* (>5WBC/hpf)
    • leukocyte esterase
  3. Nitrites (90% bacteria causing)
  4. Hematuria
  5. +/- cloudy urine
  6. increase pH with Proteus
  7. WBC casts with pyelonephritis
  8. Dipstick: + leukocytes esterase, nitrites, hematuria, WBCs (WBC casts w/ pyelo)
  9. Urine culture (definitive dx)
157
Q

Describe a positive urine culture w/ a clean catch specimen

A

10^5 (100,000)

*epithelial (squamous cells)= contamination

158
Q

Management of uncomplicated cystitis

A
  1. increase fluid intake
  2. void after sex
  3. pyridium (phenazopyridine- bladder analgesic)
  4. Nitrofurantoin (Macrobid) 100 BID x 5-7days
  5. FQ: Cipro 250mg BID x3days
  6. trimethoprim-sulfamethoxazole double strength (bactrim-DS) BID x3 days
159
Q

Do not use pyridium (phenazopyridine- bladder analgesic) no longer than ___ due to:

A

no longer than 48 hrs due to increased SE:

  1. methemoglobinuria
  2. hemolytic anemia
160
Q

Tx of Complicated cystitis

A
  1. FQ (Cipro) PO or IV

2. AG x 7-10 days

161
Q

Tx of cystitis in pregnancy

A

tx 7-14 days w/ amoxicillin or nitrofurantoin

162
Q

Tx of pyelonephritis

A

FQ (Cipro) PO or IV, aminoglycosides x 14 days

163
Q

Tx of pediatric febrile UTI

A
  • infants < 2 m/o should be hospitalized and undergo a full septic w/u due to risk of bacteremia or urosepsis)→ treated with 2 antibiotic regimen given IV
  • Outpatient treatment: Second/Third generation cephalosporins (cefprozil, cefdinir (QD), cefixime (QD), and IM ceftriaxone) X10 days
164
Q

Tx of pediatric uncomplicated cystitis

A
  • Initial antibiotic regimens for 2-13 y/o (cephalosporin regimens mentioned in Febrile UTI);
  • 13 y/o + trimethoprim-sulfamethoxazole (Bactrim) or cephalosporin
  • Treatment duration 5-7 days
  • Educate sexually active girls about method of birth control as spermicide is a risk for UTI
165
Q

Who needs VCUG imaging after UTI

A
  1. all febrile pediatric UTI
  2. non-febrile pediatric UTI: <3/o F w/ first UTI and all girls with recurrent
  3. Feverile and non-febrile UTI: all males, poor growth, hx of urologic abnormalities, FH of renal disease
166
Q

the most common types of urinary tract malformations

A
  1. vesicoureteral reflux (VUR)
  2. ureteropelvic junction (UPJ) obstruction
  3. Posterior urethral valves (PUVs)
167
Q

What is vesicoureteral reflux (VUR)

A

the abnormal flow of urine from your bladder back up the tubes (ureters) that connect your kidneys to your bladder.

168
Q

What is Posterior urethral valves (PUVs)

A

extra flaps of tissue that have grown in his urethra, the tube that leads from the bladder to the tip of his penis.
-These extra flaps of tissue block the normal flow of urine, which can damage organs such as the bladder and kidneys

169
Q

what is reteropelvic junction (UPJ) obstruction

A

an obstruction of the flow of urine from the renal pelvis to the proximal ureter

PANCE Practice (26 decks)

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