Pediatric Board Study #1 10/2020 Flashcards
What is an “apophysis”?
A protuberance
TIP: It “POP”s out
What is the presentation of Sever’s disease? What type of activities cause it?
Sever’s disease is calcaneal apophysitis
Athletes with cleats or poorly cushioned heels
What are the 3 places the calcaneus experiences stress?
1) Plantar fascia pulls
2) Achilles tendon pulls
3) Ground impact
What physical exam finding can demonstrate a patient tends to pronate their foot?
Pronate foot (pinky toe up in the air) Supinate foot (inverting foot like in an ankle roll)
Patient jump in air: foot will pronate when bending knees and knees will become valgus (knock kneed)
Relationship between pronating foot and sever disease?
Pronating feet -> more stress on plantar fascia -> risk for Sever disease
Hence: medial arch support to keep from pronating
First test to evaluate esophageal dysphagia?
Upper GI series
CLINICAL TIP: In adults, EGD is first choice
Charactersistics of Beckwith Weidemann Syndrome?
Overgrowth syndrome for neonate
Overgrowth of body: hemihypertrophy/macroglossia
Overgrowth of organs: hepatosplenomegaly
Overgrowth of pancreas: prolonged neonatal hypoglycemia
Overgrowth of cancer cells: Wilms tumor/Neuroblastoma/Hepatoblastoma
Overgrowth of heart: Cardiomegaly
Overgrowth of kidney: Nephromegaly
Differential diagnosis of patient with hemihypertrophy?
Beckwith weidemann syndrome Klippel Trenaunay Weber Syndrome Proteus Syndrome (PTEN hamartoma tumor syndrome) NF Type I Isolated Hemihyperplasia
Autonomy is to adult patients as BLANK is to pediatric patients
“Parental Authority”
That is the autonomy that parents have to make a decision on behalf of their children
How diagnose acute rheumatic fever?
Evidence of strep infection AND 2 major criteria
Evidence of strep infection AND 1 Major/2 Minor criteria
TIP: “Major Jones” sounds like a person in the military
J: joints O: heart - carditis N: subcutaneous nodules E: erythema marginatum S: Syndeham Chorea
Treatment of Acute Rheumatic Fever (ARF)?
TIP:
Think of ARF as an inflammatory sequalae of a an infection
Treat infection: Penicillin
Treat inflammation: ASA
What is the age appropriate way of thinking for preschoolers?
Preschoolers are 3-5 yo
- Magical thinking, that is, unable to separate fantasy from reality
- See themselves as the “center of the world”
- Do not appropriately see the link between cause and effect
Where can I find out guidelines to care for survivors of cancer?
www.survivorshipguidelines.org.
Why is rectal temperature measurement contraindicated for neutropenic patients?
Concern for risk of bacteremia from rectal trauma
At what elevated temperature is there a posed risk to a patient?
Difference between fever and hyperthermia is that the former is physiologic while the second is pathophysiologic
107 F
42 C
At what age is rectal temp no longer the way to go?
> 3 years old given the trauma
Preferred means of measuring temperature in a child < 3 yo?
Rectal thermometer
Infrared of the ear or the temporal artery is NOT accurate in < 6 months
Definition of “Severe” Malaria?
Any one of the following:
- Severe anemia
- Organ damage: renal failure, ARDS, cerebral malaria,
- Shock
- Metabolic acidosis or hypoglycemia
- Parasitemia > 5%
Treatment for malaria?
Quinidine + Tetracycline (OR Clinda)
What physical exam finding distinguishes Crouzon vs Apert Syndrome?
Apert has mitten hands
What is the chromosomal abnormality of Klinefelter Syndrome?
XXY
Picmonic
What are the features of Klinefelter Syndrome?
- Tall
- Gynecomastia
- Small testicles (primary hypogonadism)
- Poor social skills
- delayed puberty
- Poor social skills, Learning disability, language delay
What is a normal arm span to height difference?
Arm span - height < 2.5 inches
How is venous return affected during the following maneuvers:
- Squat:
- Valsalva:
- Standing:
- Squat: increase venous return (opposite of standing, or think of squatting like exaggeration of walking which causes venous return)
- Valsalva: decrease venous return (MOA: increased intrathoracic pressure takes up more space in the thoracic cavity leaving less room for venous return)
- Standing: decrease venous return
How should murmur of HCM vs AS differ when valsalva? When squatting?
HCM: louder with valsalva, lower with squat
Explanation:
- In normal circumstances, increase flow through a cardiac lesions causes a louder murmur. Increased venous return is an example.
- HCM is the opposite. Murmur is caused by the interaction between Septum and Mitral valve. Since increased venous return “separates” the two from each other, murmur decreases
How does hang grip maneuver affect murmurs? (General framework)
- Handgrip increases afterload
- Forward flowing murmurs (e.g. AS, HCM) decrease with hand grip since it’s a counter force
- Backward flowing murmurs (e.g. mitral regurgitation) increase with hand grip
What part of the body do actinomycetes infections present?
Cervicofacial
Actinomycetes picmonic
- Golden tree: branching chains
gram positive bacilli - Head and neck with tree coming from top: cervicofacial presentation like neck massage
- dentures hanging on the tree: oral flora
- Abe Lincoln with blue light saber cutting down teeth: penicillin
Why does humidity increase the risk of heat exhaustion and heat stroke?
Humidity means more water in the air. Keeps sweat on skin from evaporating. Less cooling.
COOL Phys: the process of evaporating liquid sweat provides cooling. It requires energy, energy taken as heat from the body, leading to cooling.
How to distinguish between heat stroke and exhaustion?
Stroke: CNS sx and 104 (40 c)
Relationship between Noonan Syndrome vs Turner syndrome?
Phenotypically similar to each other but Noonan has normal karyotype.
Cardiac defect of Noonan Syndrome
Pulmonary stenosis
What are the skin changes associated with long term topical steroid use?
Hypopigmentation, atrophy and TELANGIECTASIA
What type of topical formulations are best tolerated?
Ointments > creams > lotions > solutions > foams
What type of potency level should be used for eczema?
Low to medium potency
Low for face and intertriginous areas
Presentation of Babesia?
Picmonic:
- ixodes scapularis: ixodia head on tick
- Maltese cross in RBC: throwing Maltese crosses
- Northeast and Midwest: Jew
- Hepatomegaly: liver shield hit by Maltese crosses
- hemolytic anemia and thrombocytopenia: broken plates and RBC from stars
What type of parenting style fosters resilience?
Authoritative parenting style
TIP: balance the rules a parent sets with encouragement and love. Does NOT mean there is no room for personal choice, but has to be age appropriate.
What is resilience?
The ability to first withstand hardship, then adapt to it, followed by recovery from it.
What is the definition of hematocrit?
Volume of RBC/the Volume of Blood usually expressed as a percentage
How does the hematocrit differ between a full term neonate and a preterm neonate? Why?
In the third trimester, iron stores from the mother are transferred to the fetus. In addition, the liver becomes more sensitive to hypoxia, producing more EPO. Preterm infants miss this last stage of increased RBC production, hence lower Hematocrit
TIP: In the fetus, the liver, NOT the kidney, acts as the producer of EPO in response to hypoxia
Most common cause of congenital hypothyroidism?
Thyroid dysgenesis which is the abnormal development of the thyroid, which is either of 3 things:
- incomplete development of thyroid tissue
- lack of thyroid tissue
- ectopic thyroid tissue that is dysfunctional
Mother has Hashimoto Thyroiditis - can fetus be affected?
No
How does cold panniculitis present? Treatment?
- Red indurated plaques, somewhat similiar appearing to cellulitis
- No treatment; reduce exposure to cold; resolvs in 3 weeks
What is panniculitis?
Inflammation of the subcutaneous fat (e.g. erythema nodosum)
What level of proteinuria in UPC is diagnostic of nephrotic range proteinuria in children?
> 2mg/g
What labs can aid in differentiating glomerulonephritis from nephrotic syndrome?
- Bun/Cr
- Complement levels
GN is associated with HTN and azotemia
Most important lab to obtain in ALL patients who present with AMS?
POC Glucose
Gold standard for diagnosing narcolepsy?
Polysomnography with multiple sleep latency tests
What are the 4 core clinical features of Narcolepsy?
1) Cardinal feature: Daytime sleepiness
- TIP: VERY COMMON SYMPTOM IN GENERAL
2) Hynagogic hallucination:
3) Sleep paralysis
4) Cataplexy
What is entailed in a Multiple Sleep Latency Test? What are features suggestive of Narcolepsy?
Patient instructed to sleep every 2 hours for 20 minutes
In Narcolepsy, sleep latency is short and REM is reached in 2 out of 4 sleep periods
What is Lemierre’s syndrome? Associated bacteria?
- Septic thrombophlebitis of the internal jugular vein
- Fusobacterium Necrophorum
What are the associated illnesses in patients with Lemieere’s syndrome?
- Classically, pharyngitis
- However, any head and neck infections, including otic and dental
10 year old previously fully a vaccinated. Underwent HSCT and is now in transmission and OFF immunosuppressive therapy - what to do in regards to Hib vaccination?
ALL children that received HSCT require 3 doses of Hib vaccine 6 months AFTER HSCT/completion of immunosuppressive therapy - REGARDLESS of prior vaccine status
What are the vaccines scheduled from 0 - 6 months of age?
- “TWO 6-MONTH-old Pediatric POLIticians DIscussed Rejecting HIs HEP B at 4 MONTHS”
- 2/6 months have the same 6 shots
- 4 mos has same shots EXCEPT Hep B
- P: PCV
- Poli: POLIO
- DI: DTAP
- R: RV
- HI: Hib
- HEP: Hep B
TIP: First 6 months, 6 shots each time.
Classic presentation of MCL sprain?
- Pain in medial aspect of knee
- Localized swelling in the medial aspect of knee
- Pain with valgus stress
Clues that MCL sprain is accompanied with other severe injuries?
Joint effusion around entire knee
What type of hyperbilirubinemia would Gilbert and Crigler Najjar present with?
Unconjugated hyperbilirubinemia
What is the pediatric definition of cholestasis from a lab stand point?
Conjugated bilirubin > 1.0 - SIMPLE!
Most common cause of neonatal cholestasis?
Biliary atresia, a progressive obliterative disease of intra/extra hepatic biliary ducts that leads to liver diseas
What are the features of Stickler Syndrome?
PICMONIC
What is Pierre Robin Sequence?
Presence of:
- Micrognathia
- Cleft palate
- Glossoptosis (retracted and downward displaced tongue, leads to obstruction)
Children with obesity should be screened for HLD and HTN. Which patients with obesity should be screened for diabetes?
- Obesity with addn risk factors:
- Family hx of Type II DM
- High risk ethnicity: Native American, Asians, Pacific Islanders, Hispanics, African americans (TIP: NOT whites/indians/middle east)
- PE signs of insulin resistance
Styne DM, Arslanian SA, Connor EL, et al. Pediatric obesity-assessment, treatment, and prevention: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;
What are the tests of choice to screen pediatric patients for diabetes?
- Fasting glucose
- A1c
- Oral glucose tolerance test
Can pediatric patients with substance use disorder be enrolled into rehab without their consent?
YES!
Can chronic use of marijuana be considered a substance use disorder?
YES! Like any other substance, even as culturally acceptable as marijuana, as long as it causes dysfunction in a patient’s life, it can be considered a disorder that requires treatment
Otalgia may be referred pain from what other part of the body?
Dental pain is the most common cause of referred otalgia
COOL PHYS: Referred pain comes from misinterpretation of the sensory cortex 2/2 overlapping innervation
The auriculotemporal branch of the mandibular division of the trigeminal nerve supplies sensory innervation to parts of the auricle, external auditory canal, and tympanic membrane, as well as the cranial cavity, scalp, orbit, face, nose, nasal cavity, nasal sinuses, mouth, teeth, temporomandibular joints, and parotid glands.
In patients with splenectomy, what characteristics place them at higher risk of sepsis 2/2 encapsulated organisms?
- Splenectomy 2/2 a primary blood disorder
- Splenectomy at a young age
- Recent splenectomy
What type of organisms are asplenic patients at risk for?
Encapsulated bacteria:
- SHiNSKiS
- Salmonella
- Hemophilus Inf
- Neisseria Meningitiditis
- Staph aureus
- Klebsiella
- Strep Pneumoniae
EXTRA: Pseudamonas, E. Coli, Group B Strep
What age group, if contracted influenza, should be treated with antivirals?
< 5 yo (high risk for complications)
Behaviors concerning for suicidal ideation?
- Distributing possessions
- Posting about suicidal thoughts via social media
Pathogen responsible for RMSF?
Rickettsia rickettsia
What is the defective enzyme of galactosemia?
Galactose 1 phosphate uridyltransferase
Associated lab abnormalities in galactosemia?
- Metabolic acidosis
- Hypoglycemia
- Coagulation disorder
- Hyperbilirubinemia
- Hepatic injury
What are the phases of Lyme disease?
- Early localized: erythema migraña
- Early disseminated:
- Carditis, heart block
- CNS, meningitis, facial palsy
- Arthritis
- Diffuse rash
- Late disseminated: large joint arthritis effusion which tends to be out of proportion with pain and inflammatory markers
Relationship between JIA and Ankylosing Spondylitis?
Ankylosing spondylitis is a subtype of JIA called enthesitis related arthropay (ERA)
Describe the arthritis of Ankylosing Spondyloarthritis
Starts with oligoarthritis of hip, knee and ankle
Then later axial skeleton
Imagine the arthritis creeping up the body to reach the back
Describe the schober test?
he Schober test is used to measure forward flexion of the lumbar spine—with the patient standing straight, a mark is made over the spinous process of the 5th lumbar vertebra; a second mark is then made 10 cm above it. After asking the patient to bend maximally forward, the distance between the 2 points is normally > 15 cm. Measurements ≤ 15 cm are consistent with limited forward flexion.
What organizations need to be contacted if non-adolescent pediatric patient is diagnosed with STI?
CPS and Health Department
What are ways to BF twins?
- Sequential
- At the same time
What technique can be used to measure patient’s fine motor skills in years when asking them to draw a person?
3 + 1/4( # points) = age
1 point for every body part:
- nose
- mouth
- pair of eyes
- pair of arms
- pair of legs
What is the one obligatory lab work for all college athletes per National Collegiate Athletic Association?
Sudden death attributed to exertional rhabdomyolysis (a.k.a. “exertional sickling”) has been reported among athletes with sickle cell trait
Patient develops herpes zoster. Under what conditions can he return to work?
Anytime as long as the lesions are covered
What is the difference between the location of the bleed in epidural hematoma vs subdural hematoma?
- Epidural hematoma: “Above” the dura. Between the skull and the dura mater
- Subdural hematoma: “Below” the dura. Between the dura and the arachnoid mater
- Review:
- Skull -> Dura -> Arachnoid mater -> pia mater
- Veins draining blood from brain parenchyma cross all the layers until reaching the dural sinuses
What is the CT findings of epidural hematoma vs subdural hematoma?
- Subdural: Crescent shaped.
- Exp: location of bleed between dura and arachnoid mater, hence, it can cross suture lines, but not midline
- Epidural hematoma: Lenticular shaped
- Exp: location is between periosteum and dura; since dura is attached to the sutures, blood can’t cross sutures
What is the most common cause of SDH in children?
Child Abuse
Most common cause of acute hoarsness?
Viral infection
Most common cause of chronic hoarseness?
Voice abuse
What is the best test to evaluate if a newborn had been exposed to illicit drugs during pregnancy?
Drug Screen of the meconium as UDS only evaluates drug exposure in the past 5 days.
What test, if present only once, is diagnostic of Type II DM?
Random glucose > 200 + Symptoms of hyperglycemia
TIP:
- A1c, Fasting Glucose > 126, or OGTT > 200 - all x 2 are diagnostic of diabetes
What autoimmune diseases are recommended to be screened at the type of diagnosis of Type I DM?
- Celiac disease
- Hypothyroid
What is the recommended caloric intake for infants with congenital heart disease?
140kcal/kg/day
Framework Question:
How much formula an infant needs each feed?
- 0-6 months: 110 kcal/kg/day
- 7-12 months: 100 kcal/kg/day
- Formula is 20kcal/oz
Framework Question:
A parent asks you: How much formula an infant needs each feed
0-3 months: at least 5 oz/kg/day
3 - 12 months: anywhere between 26 to 32 oz/day
- TIP: AKA if feeding 8x/day, anywhere between 3 oz/feed to 4 oz/feed
Pediatric patient just diagnosed with Juvenile Myasthenia Gravis, what is the next step in work up?
CT Chest to evaluate for thymoma
What is the treatment for Myasthenic Crisis?
- Plasma exchange OR IVIG, both aiming to reduce the burden of autoantibodies
What common meds can worsen Myasthenia Gravis?
- Antibiotics: Fluoroquinolone, Macrolides and Aminoglycosides
- Magnesium
- STEROIDS! - cause a transient worsening of symptoms in the first 2 weeks
What is areas are evaluated in a FAST exam?
- Hepatorenal recess
- Splenorenal recess
- Suprapubic recess
- Subxyphoid view to evaluate for pericardial effusion
Presentation for ichthyosis vulgaris?
- Hyperkeratotic scales on the extensor surfaces
- Hyperlinear palms
- Sparing the flexural surfaces
Treatment for ichthyosis vulgaris?
- Emollient containing alpha hydroxy acid (e.g. ammonia lactate)
What is the preferred treatment for C. Diff in children? Adults?
Children:
- Non severe: Metro vs oral vanc
- Sever: Vanc
Adult:
- Non severe: Vanc
- Severe: Vanc +/- metro
TLDR: Adult use vanc, vanc, vanc; Children use metro or vanc, but def vanc in severe disease
Are there any adverse effects of lead exposure at low levels, that is < 5 µg/dL?
YES!
- Children with lead levels < 5 are more likely to be diagnosed with ADHD and lower IQ’s
- Pregnant mothers with lead levels < 5 are more likely to have small birthweight children
Mother of a newborn is found to have elevated lead levels. How should she be counseled in regards to breastfeeding?
No breastfeeding since lead can be transmitted through breast milk.
PICMONIC: breast with lead pencils
What is the recommendation in regards to the use of renal ultrasound and VCUG in infants with UTI?
- ALL children < 24 mos of age require RUS for their first febrile UTI because there are high risks for anatomic abnormalities.
- VCUG is pursued later if RUS demonstrates any abnormalities to evaluate for VUR
What amount of bacteria in urine specimen is diagnostic of UTI in infants? (depending on the method of obtaining urine culture)
TIP: The move invasive the procedure, the lower amount of bacteria required to diagnose UTI since it is more sterile and less likely to be contaminated
- Suprapubic aspiration: ANY bacteria
- Urinary catheterization: >50k CFU
- Clean catch specimen: > 100k CFU
What is the BEST test and timing of test to diagnose chronic HCV in a newborn, born to a mother with untreated HCV?
HCV Ab at 18 months
- Exp: Key is chronic infection. If HCV RNA is measured soon after birth and is positive, it may clear eventually, so positive test does NOT mean chronic Hep C. At 18 months, maternal HCV Ab will have cleared from baby’s system.
What is the perinatal transmission rate of Hep C from mother with untreated Hep C?
5% only!
TIP: Hep C as an adult will likely be chronic, less likely transmit to baby. Opposite to Hep B, which is less likely to be chronic, high likelihood of perinatal transmission.
In “adolescent idiopathic scoliosis”, what is the degree of curvature that all patients will need bracing or surgical intervention?
25%
Framework question:
What are the 2 most important factor in determining if an adolescent will need referral to Orthopedics for evaluation of scoliosis for treatment?
- Skeletal maturity (Risser Score)
- Degree of curvature (“Cobb angle”)
- Exp: Skeletal maturity matters because patients that have yet to reach full skeletal maturity have more room to grow. It is during the growth phase that scoliosis worsens the most. If skeletal maturity is near, further changes are NOT expected. Degree of curvature predicts symptoms and morbidity.
What is the typical organism to cause septic joint/osteomyelitis in toddlers?
Kingella Kingae
Toddler with septic joint has aspiration performed, but no growth of fluid. What next step can help diagnose the bacterial cause?
PCR assay can help diagnose Kingella (and other organisms) that are difficult to culture
What are the characteristics of Treacher Collins Syndrome? (PICMONIC)
- Small Ears, Large nose, Small mouth: Rat
- Eye abnormalities/Vision abn (vision loss, amblyopia, refractive errors, strabismus): Binoculars
- Pierre Robin Sequence: bird watching
- Treacher: “Preacher”
Parent asks you: What will be some of the intellectual disabilities that my son, who has Treacher Collins, will have?
NONE!
Peds Hospitalists who had Treacher Collins Syndrome!
What is the pubertal sequence of events for boys vs girls?
- Girls: Breast development → Pubic hair → Peak height velocity → Menarche.
- Boys: Testicular enlargement → Pubic hair → Increased penile length → Peak height velocity.
When does puberty start for girls vs boys?
Puberty in girls begins between 8 and 13 years of age and in boys between 9 and 14 years of age.
TIP: 8 looks like breasts; 9 looks like testicle/penis
What is the diagnosis of delayed puberty for girls vs boys?
Puberty in girls begins between 8 and 13 years of age and in boys between 9 and 14 years of age.
So, for girls it is no puberty (Breast buds) > 13, boys is no puberty (no testicular enlargement) > 14
When does vaginal leukorhhea occur in regards to puberty?
Anytime within the year prior to menarche
TIP: think of the white discharge as the herald for the red discharge (menses)
Explain the physiology of Eisenmenger syndrome in patients with VSD?
Unrestricted VSD, that is, a VSD in which the pressure between the right and left ventricle is normalized, leads to increased blood flow from the left side of the heart to the right. This increased volume to the right side leads to pulmonary HTN and resistance. Eventually, right side pressure becomes greater than left such that shunt goes from right to left - blue blood goes to red blood.
What scenario does a patient presenting after a human bite require Tetanus IG?
Patient who has < 3 tetanus vaccinations OR unknown who comes in with a human bite needs TIG.
THIS IS THE ONLY SCENARIO IN HUMAN BITE THAT REQUIRES TIG
When does a patient presenting with a human bite require a tetanus vaccination?
- < 3 tetanus vaccinations or unknown
- > 3 tetanus vaccinations, BUT > 5 yo since you are nearing the time of booster which means immunity is waning (booster in general is needed between 4-7 years of age)
Differential diagnosis for a patient who develops a fever and hypotension in the middle of a transfusion?
- Sepsis
- Febrile hemolytic transfusion reaction
- Febrile non-hemolytic transfusion reaction
- Allergic reaction given hypotension
TIP: blood cultures, antibiotics and labs to evaluate for hemolysis
What is the toxidrome of clonidine toxicity?
Clonidine is a central alpha 2 agonist, working centrally to decrease the transmission of NE (think of ADHD) as well as decrease the sympathetic outflow peripherally.
Hence, central AND peripheral effects
- Central: sedation
- Peripheral: bradycardia, hypotension (as a result of decreased sympathetic outflow)
- Respiratory: apenea, respiratory depression
What is the treatment of choice for children with OCD?
- If mild, CBT
- If CBT is not sufficient, addition of SSRI is recommended
What are the FDA approved medications to treat pediatric OCD?
- Fluoxetine
- Sertraline
- Fluvoxamine
What are some characteristic differences between OCD in children and adults?
The obsessions (or intrusive thoughts) for children are more harmful or violent than adults
What is the presentation of osteoid osteoma?
Localized pain at tibia or fibula ( 50% of the cases)
Not associated with activity
Responds well to NSAIDS
What is the main treatment for ostenopenia/osteoporosis due to anorexia nervosa?
Adequate caloric intake is the main stay
Secondary treatments include Vit D/Calcium, weight bearing exercises
How does CKD (and ESRD) in children affect their linear growth?
Decreased linear growth compared to normal children
How to treat impaired linear in children with CKD (and ESRD)?
Growth hormone replacement (before puberty)
INTERESTING (and sad): Short adult height in patients with end-stage renal disease is also associated with lower self esteem, decreased education, marital status, and decreased income.
What is the first line treatment for Guillain Barre: IVIG or Plamapharesis?
IVIG (AND Plasmapheresis). Both have similar efficacy. IVIG is more tolerable. And plasmapheresis is reserved for cases of severe respiratory failure
What are the classic characteristics of Miller Fisher Variant of Guillain Barre?
Triad of Ophthalmoplegia, Areflexia and Ataxia.
TIP: the ataxia and ophthalmoplegia are the key differences between GBS and Miller Fisher Variant
TIP: any CN OR brainstem involvement, think of Miller Fisher
Pediatric patient presents after a house fire sustaining severe burns.
1) How do you calculate the fluid deficit?
2) Over what time period should this fluid deficit be replaced?
- Parkland formula: 4ml/kg x weight (in kg) x body surface area affected (%)
TIP: think of a park on fire.
- First 24 hours
What is the way to calculate the surface area % affected in a burn victim?
“Rules of 9” Girl diagram
What is the total fluid requirement of a child who presents following severe burns?
Fluid deficits from burns + fluid maintenance for the day = fluid deficit for the first day
Parkland formula + Holliday Segar
4ml/kg x weight (kg) x surface area burned (%) + 100 x weight (kg) = total fluid needs of the first day
What is the relationship between postpartum depression and developmental delay?
Post partum depression is a risk factor for developmental delay
What are the milestones of a 2 mos old
PICMONIC or Mnemonic
- Chest up in prone position
- Holds hands together at midline; holds rattle
- Coos
- Social smiles
Picmonic: Imagine baby swan; prone; rattle between 2 hands; chin propped up and chest off the ground; smiling big to camera;
“2 is coo”
What is first line treatment for functional constipation in kids?
Polyethylene Glycol
What are signs that a child presenting with functional constipation may need disimpaction?
Fecal incontinence
What is the characteristic presentation of HSP?
Palpable Purpura
Abdominal Pain
Arthritis
Hematuria
What are the most common organs involved in HSP?
Skin (edema/palpable purpura) > Arthritis > GI > Renal
TIP: Though renal is the least common organ affected in the classic presentation. It is the one that warrants follow up
What are the possible renal manifestations of HSP?
Which require Nephrology co-management?
- Renal involvement is seen in 30% to 50% of children and presents with varying severity including NO inolvement, microscopic hematuria, macroscopic hematuria, proteinuria, nephrotic syndrome, nephritic syndrome, and rapidly progressive glomerulonephritis
No involvement: monthly UA
Hematuria or non-nephrotic range proteinuria: weekly UA
The rest: Nephrology
What is the presentation of nasal foreign body?
Unilateral rhinitis, possible green-yellow discharge
Foul breath odor
What is the presentation of allergic rhinitis?
Characteristic physical examination findings include edematous, pale, or bluish nasal turbinates; allergic shiners; Dennie lines (folds under the eyes because of edema); and a transverse nasal crease.
What is the best screening test for Lesch-Nyhan Syndrome?
The best screening test for Lesch-Nyhan syndrome is a urinary urate-to-creatinine ratio, which will be greater than 2.0 in a child who is younger than 10 years of age
WATCHOUT: Hyperuricosuria and hyperuricemia (serum uric acid concentration >8 mg/dL [476 µmol/L]), while often present, are not sensitive or specific enough to confirm the diagnosis.
What is the biochemical defect in Lesch Nyhan? Inheritance?
- Hypoxanthine-guanine phosphoribosyltransferase enzyme activity is reduced leading to excess uric acid that deposits
- X Linked - hence, ONLY boys are affected; girls who are carriers are NOT affected
What is the treatment of uncomplicated sexually transmitted N. Gonorrhea?
The recommended treatment regimen for uncomplicated N gonorrhoeae infections of the cervix, urethra, and rectum is ceftriaxone 250 mg intramuscularly in a single dose (if unavailable, cefixime 400 mg orally as a single dose) PLUS azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days
Reason is because of resistance
What is the difference between Indomethacin and Prostaglandin in regards to congenital heart disease?
- They are the opposite - one is an NSAID the other is a prostaglandin
- Prostaglandin OPENS the PDA is needed in ductal dependent pulmonary or systemic flow
- Indomethacin closes the PDA
5 day old presents with cyanosis and tachypnea, but is comfortable. Start Prostaglandin. Why?
- Patient has CHD that is ductal dependent, likely to pulmonary flow. At birth PDA was open so pulmonary flow was adequate, but as PDA closes, cyanosis occurs in the case of ductal dependent pulmonary flow
When does PDA close for term infants?
- Functionally, the first 24 hours of birth
- Complete closure doesn’t occur until 3 weeks
What age group is at risk of severe rotavirus infection, that is, severe dehydration?
- 6 mos to 2 years, hence the recommendation of RV vaccination from 2-6 mos of age.
Parent asks you: when should they start brushing their child’s teeth?
Brushing with fluoridated toothpaste should begin with first tooth eruption
Parent asks you: How much toothpaste does their child need?
< 3 yo: grain of rice size
> 3 yo: pea size
What is the AAP recommendation in regards to applying fluoride varnish?
The AAP recommends application of fluoride varnish every 3 to 6 months to both primary and permanent teeth starting at tooth eruption
What is the definition of acute liver failure?
Coagulopathy (INR > 1.5) and encephalopathy that occurs acutely (< 26 weeks)
In children, how is the definition of acute liver failure different from adults?
If INR > 4, diagnosis can be made without the presence of encephalopathy
What are the causes of ALF in children (across all age groups)?
- 50%: unknown
- Infectious: EBV, Adenovirus, Parvovirus, HSV are most common.
- TIP: Hep A, B and C are uncommon causes in children
- Toxins: Acetaminophen, phenytoin, valproic acid, isoniazid
- Metabolic: Wilsons, galactosemia, tyrosinemia, urea cycle defects, and mitochondrial disorders
- Autoimmune:
- Ischemic: Budd Chiari Syndrome
Parents of a severely visually impaired child as you what type of training their child may need to make sure they can navigate school safely. What available training is there?
Orientation and mobility training is essential to ensure that children with visual impairment are able to navigate their environment safely and effectively
Definition of blindness in regards to visual acuity?
20/400 or worse when best corrected for visual acuityP
Parent asks you: what is a good resource to learn about the special learning needs of my visually impaired child. You respond:
These are outlined in the American Foundation for the Blind Expanded Core Curriculum
Differential diagnosis of neonate with decreased activity or level of consciousness
HYPOGLYCEMIA, early onset sepsis, seizure, metabolic disorder
What type of infections, if recurrent, help you distinguish between a primary immunodeficiency of the innate immune system vs the adaptive immune system?
- Recurrent bacterial infections suggest innate immune system
- Recurrent or atypical viral infections suggest adaptive immune system
Chronic Granulomatous Disease Picmonic
- X linked: X ninja stars
- Oxidative burst defect: bubbles of grandmas stuck with X marks the spot
- Skin and lung infections: girl in bikini flying around with a jet pack, with staff popping bubbles
- Staph aureus abscesses
What is the gold standard for testing for CGD?
Flow cytometry to access oxidative burst, achieved through testing of the Dihydroxy-rhodamine 123 reduction
What is the difference between hamartoma vs teratoma?
Hamartoma is a tumor made up of the cells normally found in the anatomic site where it is found. It is also always benign.
Teratoma is a tumor made up of cells that differentiate toward somatic cells (typical of adult or embryonic development) NOT normally found in the anatomic site where is is found. Can be malignant
What is the presentation of nevus sebacus?
Tan, hairless plaque with a velvety texture that was present at birth.
COOL PHYS: A nevus sebaceus is a hamartoma, composed of sebaceous and apocrine glands and epidermal elements, that is present in 0.3% of newborns. It will grow in puberty because androgens will have affect on the sebaceous glands as is the case in other parts of the body
What is the diagnosis of HHS?
TIP: Hyperglycemia and the absence of DKA labs
BG > 600 + OSM>320 + absence of DKA (pH >7.3, Bicarb > 15, little to no ketones)
What is the difference in treatment of HHS in regards to insulin therapy?
Insulin rate is lower: 0.05 u/kg/hour (instead of 0.1 u/kg/hour)
What scenario do most mumps outbreaks occur?
VACCINATED close quarters!
TIP: 2 dose mumps vaccination only confers 88% immunity
What is the approach to evaluating a child with concern for acute cerebellar ataxia?
- Ruling out other dangerous causes of acute ataxia
- Normal MRI
- Normal Lumbar puncture
Difference between “acute cerebellitis” vs “acute cerebellar ataxia”?
“Acute cerebellitis” is more severe and associated with encephelopathy
What age group does acute cerebellar ataxia usually affect?
2-5 years old
What is the difference between non-typhoidal salmonella vs typhoidal salmonella?
Typhoidal salmonella: resource limited countries, fever and constitutional sx predominate some abdominal pain due to bacteremia
TYPHOID FEVER occurs in resource limited places
Nontyphoidal salmonella: US, gastroenteritis predominant presentation
What is scanning speech? What neurologically is affected in a patient who presents with scanning speech?
- slow speech that emphasizes al the syllables, almost like slurred speech
- Ataxia, hence cerebellar
Long QT syndrome and sensorineural hearing loss - what is the syndrome?
Jervell Lange Nielson Syndrome
What does the presence of reducing substances in the urine indicate?
Carbohydrate metabolism disorder
Explanation: Sugars or carbohydrates have the ability to reduce other substances e.g. cupric ions to cuprous ions. The presence of the reducing substances in the urine implies carbohydrates in the urine. The presence of carbohydrates in the urine implies excess carbohydrates. This implies carbohydrate metabolism disorder
TIP: so fatty chain oxidation disorders do NOT have reducing substances in the urine
Describe the rash and fever relationship/characteristic of roseola infantum
Rash comes AFTER the fever (when defervescence occurs)
- Starts in the trunk and spreads to the face, neck and extremities; lesions are distinct, discrete and can be papular
Age of Roseola infection
6-15 months (TIP: same as febrile seizures)
What are the adverse effects of taking recombinant growth hormone for athletic performance?
Development of diabetes
Hypertension
Cardiomegaly
TIP: become the opposite of an athlete, someone with heart disease, HTN and diabetes
What is the transmission rate of syphilis in utero if mother is untreated?
Nearly 100%
What are the bone manifestations of congenital syphilis?
Osteochondritis and periostitis
Characteristic findings of Trisomy 13?
- Overlapping fingers
- Dysplastic nails
- Rocker bottom feet
Prognosis of Trisomy 13?
Most die within 1 year
Median survival is 2 weeks
Cause of death usually due to renal anomalies or heart defects
Does adverse effect of a medication need to be reported to the FDA or the manufacturer of a drug?
No, even death
Empiric antibiotics for retropharyngeal abscess?
Penicillin + Beta Lactamase Inhibitor
What is the classic presentation of retropharyngeal abscess?
Triad: Torticollis, Fever and Odynophagia
What is the associated cardiac defect with Williams Syndrome?
Supravalvular aortic stenosis
What is the characteristic disposition of those with William Syndrome?
Strong expressive language skills, socially engaged, polite and very endearing
“Elfin appearance”
What are the most common cardiac anomalies associated with fetal alcohol syndrome?
VSD
TIP: Remember that alcohol ablation is used to treat HOCM. So, alcohol during fetal period is a natural “ablater” of the septum
Infant is born to Hep B Positive mother. What are the next steps and what are the recommendations for Hep B vaccination in this population?
- At birth: HBIG and HBV vaccine
- Then HBV at 1, 2, 6 months
TIP: DO NOT COUNT HBV at birth as one of his vaccines.
Preterm infant is born and weights 1.7 kg. HBV vaccine?
No, because seroconversion rate is low in infants < 2kg. So, no HBV at birth. But at 1 month of age, regardless of weight, seroconversion rate is similar to term infants
How is treatment of Ramsey Hunt Syndrome different from other herpes zoster infections ?
Acyclovir AND STEROIDS
What is the presentation of Ramsey Hunt Syndrome?
TIP: presentation is the sequelae of cranial nerve 7 and 8 involvement
- Vesicular rash around and in the ear canal (oropharynx, soft palate and 2/3 of tongue)
- Facial nerve palsy
- Tinnitus, vertigo, hearing loss, ataxia
PICMONIC Ramsey Hunt Syndrome
Ramsey Hunt - King tut hunter shooting an arrow
- Shooting arrow into a giant ear
- Missing and hitting the bell located on the ear lobe
- Standing on a cliff (CN 7)
- Handcuffed to the ground (CN 8)
What is the disorder in which acute infection worsens psychiatric symptoms such as OCD?
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections)
COOL PHYS: Autoimmune anti streptococcal antibodies cross the BBB and cross react with tissue and affect caudate, putamen and pre-frontal cortex
Treatment of C1 esterase inhibitor deficiency associated with Angioedema?
Danazol increases the level of C1 esterase inhibitor
How does daycare attendance affect with antibiotic resistance?
Increases it in Strep Pneumoniae
What is the most common gene defect known to cause hereditary pancreatitis?
PRSS1 gene
TIP: Think press the pancreas
Cool phys: Gene mutation leads to defective trypsinogen that prematurely converts to trypsin while still in the pancreas and causes inflammation
What is the duration of immunosuppressive therapy in renal transplant patients?
As long as the graft is there, immunosuppresive therapy will be required
TIP: LIFELONG
What accounts for the difference between living and deceased donor renal transplant survival?
The deceased donor has longer cold ischemia time. So reperfusion injury is more common
Initial imaging test in cases of choledocolithiasis?
Abdominal U/S
What visual acuity, if present, warrants further evaluation prior to clearance for sports?
Corrected visual acuity worse than 20/40
Do Down Syndrome patients require radiographs of spine prior to participating in sports?
Although AAI has been reported in up to 27% of individuals with DS, only 1% to 2% experience symptoms. Best evidence indicates that identification of AAI on cervical spine radiographs in asymptomatic DS patients does not predict future injury in those who participate in unrestricted sports activity. AAP does not recommend screening cervical spine radiographs in these athletes if they are asymptomatic and have normal neurologic examination findings.
Interesting: Special Olympics requires radiographs
Pediatric patient has moderate pain post-op. Morphine vs tramadol?
Tramadol and Codeine are NOT recommended given variable metabolism and concern for undertreatment of pain.
Morphine is preferred
In 2012, the World Health Organization published the Guidelines on the Pharmacologic Treatment of Persisting Pain in Children with Medical Illnesses
What is the leading cause of morbidity and mortality in drowning?
Cerebral hypoxia
What is the best way to diagnose West Nile Virus meningoencephalitis?
Serology (IgM/IgG) of BOTH the CSF and blood
TIP: Though called WNV, it is common all over the US
Where is West Nile Virus common?
Most US states, with the highest numbers seen in California, North Dakota, South Dakota, Oklahoma, Colorado, and Nebraska
How does the presence of viral symptoms in the setting of pharyngitis affect the likelihood that a patient has strep pharyngitis?
Viral symptoms such as conjunctivitis, cough, coryza make the likelihood of Group A Strep pharyngitis less likely.
In a patient with hypercarbic respiratory failure from opioid overdose, he is also found to be hypoxic. Explain how?
Simply, how is hypercarbia accompanied by hypoxia in hypopnea?
- Decreased air intake leads to decrease O2 in alveoli
- Decreased ventilation leads to alveolar collapse, which leads to intrapulmonary shunting (pulm blood flow through collapsed alveoli)
- As CO2 increases in the alveoli, O2 decreases, as consistent with the ideal gas law that PV= nRT. P is total pressure exerted by the sum of the partial pressure of each molecule. In order for P remains the same, if partial pressure of CO2 increases in hypercapnia, then partial pressure of O2 must decrease.
How common is it for a patient with ADHD to have co-morbid illnesses? What are some co-morbid illnesses?
75%! It is the rule, not the exception
- Anxiety, depression, speech/language disorder, autism spectrum disorder, learning disability, oppositional defiant disorder, and tic disorders
Which ADHD meds are associated with high blood pressure?
Stimulant meds such as amphetamine/methylphenidate and Atomoxetine
TIP: NE reuptake inhibitor, hence more NE, vasoconstrictor
What children is it recommended to obtain a chromosomal microarray?
All children with developmental delay, multiple congenital anomalies or intellectual disability of unknown etiology
Wolf Hirshhorn Syndrome PICMONIC? Chromosomal abnormality?
4 p deletion: Sail boat
- picmonic for “P”: pearl
- sailing toward an island with pearls and clams
Facies: wolve with a “greek helmet”, small ears with large holes (like african tribes)
- Greek helmet nose
- Ear pits
Antibody deficiencies (69%) - Zangief tied to the mast by kidneys and ureters
cardiac defects (50%) - Wolf with spear pierces piercing heart/brain
urinary tract anomalies (30%) -
central nervous system malformations (80%) -
What infants require screening for ROP?
- Born 30 weeks or less
- Born less than 1500 gm
COOL PHYS: abnormal growth of the retinal blood vessels sometimes INTO the vitreous and causing retinal detachment. Hence laser for photocoagulation to stop vessel growth
What is the difference between the timing of the pain from Mittelschmerz vs Primary dysmenorrhea?
Mittelschmerz occurs from ovulation, hence 1-2 weeks BEFORE menses and should ONLY last 1 day the most
Primary dysmenorrhea occurs right before menses and into menses
What is an abnormal congenital heart screen with pulse ox for a newborn?
- O2 sat < 90% x 1 - DUH
- 90-95% OR greater than 3% difference between right foot and right hand x 3
How common is renal involvement in SLE?
2/3
What is the difference in the presentation of “jerk nystagmus” and “pendular nystagmus”?
- Jerk nystagmus involves a slow phase followed by fast phase.
- Pendular nystagmus is a slow sinusoidal oscillation
What is the presentation of Spasmus Nutans?
Spasmus nutans is a childhood condition characterized by a clinical triad of dysconjugate pendular nystagmus, torticollis, and head bobbing (this is the “spasms”)
Key difference between congenital nystagmus vs spasmus nutans?
Congenital nystagmus present at birth, but usually diagnosed at 3 mos of age
Spasmus nutans diagnosed between 6 mos to 1 year of age
They are both on the differential for infants with nystagmus
What are clues from urine electrolytes and urinalysis with microscopy that implies ATN?
- SG < 1.020 - tubular dysfunction
- epithelial casts - tubular dysfunction
- FeNA> 2% - tubular dysfunction
- Na > 20
First line options of GER in infants (pharmacological)?
- Thicken feeds and avoid overfeeding
- If persistent, can trial hydrolyzed formula or have mother eliminate dairy from her diet (if breastfeeding)
Patient presents after having over extended a finger during football practice. How to assess the functionality of the flexor digitorum profundus and flexor digitorum superficialis?
TIP: flexion of the fingers occurs through these 2 tendons
Test flexor digitorum profundus: hold the middle phalanx of the suspected injured finger to prevent PIP from flexing; ask patient to flex so to test flexion of the DIP
Test flexor digitorum superficialis: Stabalize the 2 fingers flanking the suspected injured finger, ask patient to flex the injured finger to test flexion of the PIP and MCP
What type of tendon injury of the hand requires an urgent referral to hand specialist?
Tendon tear as noted by digitorum profundus and flexor digitorum superficialis on exam
What are the characteristics of a Still’s Murmur?
A Still murmur is a classic innocent murmur typically described as a low-pitched, musical, 2/6 systolic murmur heard best at the lower left sternal border that changes with position and is not heard during the Valsalva maneuver.
What are scenarios in which minors are emancipated?
- Married
- Joined the military and are active
- Judge granted
Difference between consent and assent?
Assent is an interactive and ongoing process between a child and a clinician wherein developmentally relevant information is disclosed about a particular intervention. During the assent process, the child is engaged and his or her input is sought. The goal of assent is to protect children’s rights by allowing them to voice their preferences when it is appropriate to do so.
TIP: Assent is like consent, but developmentally appropriate for the age.
Diagnosis of Kawasaki’s Disease?
“5,4,3,2,1” Rule
5 days of fever
4/5 symptoms:
- B/l conjunctivitis, non-purulent
- Oral findings: red tongue, chapped lips
- Lymphadenopathy > 1.5cm
- Hands/Feet: Desquamating rash, edema
- Diffuse rash described as maculopapular or erythoderma
3 supplementary labs: Leukocytosis, Anemia, Thrombocytosis, AST/ALT, hypoalbuminemia, leukouria
2 inflammatory markers: CRP/ESR
1 ECHO finding
Treatment of Kawasaki’s?
High dose ASA (100mg/kg)
IVIG 2gm/kg
Skin infection from Pseudomonas - What is it called? Presentation?
Ecythema Grangenosum
Painless, necrotic, ulcerative cutaneous lesion with a gray-black eschar with surrounding redness.
By what age are feeds in the middle of the night unneccessary for infants?
6 months
Describe the extinction technique and how that may reduce the amount of night time awakenings an infant may have
- Put the baby to bed when awake, but drowsy
- Nightly, wait progressively longer times prior to checking up on infant (extend by 10 minutes/night)
- When checking on child, limit to 1-2 minutes and soothe by patting, NOT carrying
What house hold items have methanol?
Winshield wiper fluid
Household solvents (TIP: solvents are substances that dissolve other things)
Perfumes
Cooking fuels
How does fomepizole treat methanol toxicity?
It competitively inhibits alcohol dehydrogenase
Alcohol dehydrogenase metabolizes methanol into formaldehyde, which later metabolizes into FORMIC acid. This is the toxic metabolite
Antibiotic of choice for neutropenic fever?
Cefepime
When do urea cycle disorders present?
Rapid decompensation first 24-72 hours of birth
Neonatal period. Hence, Urea cycle defect should be on the diff/diag in a neonate who decompensates
What labs are indicative of a urea cycle disorder?
- Hyperammonemia
- Progressive respiratory alkalosis due to the above
- NAGMA
- Normal glucose
COOL PHYS: Urea cycle is the cycle by which proteins are broken down. Nitrogen is broken down to urea that is excreted in the urine. Build up of nitrogen leads to accumulation in the form of ammonia, hence hyperammonemia implies a protein metabolism defect, hence urea cycle disorder
What is the inheritance pattern of OTC?
X linked
TIP: this is the ONLY urea cycle disorder that is NOT recessive. ALL are recessive.
What labs can be ordered to help distinguish between the urea cycle disorders?
Urine Orotic acid and plasma amino acids
Urine orotic acid, if high, indicates OTC
Plasma amino acids demonstrate which AA are not being metabolized appropriately
Newborn with congenital toxoplasmosis is asymptomatic. Treat?
Yes, 3 months of Pyrimethamine, Sulfadiazine and Folinic acid
Can healthy children present with severe Toxoplasmosis infection?
Yes, no need to be immunocompromised
Patient is diagosed with Toxoplasmosis but is asymptomatic. No need for treatment. When will patient need prophylaxis?
Whenever patient becomes immunocompromised. For example, new diagnosis of leukemia.
Reason: Acute toxoplasmosis is due to reactivation of previous infection instead of new primary infection
What ethnicity places a patient at risk for human trafficking?
American Indian
What populations do AAP recommend the quadravalent meningococcal conjugate vaccine?
American Academy of Pediatrics (AAP) approved updated recommendations for the use of quadrivalent (serogroups A, C, W-135, and Y) meningococcal conjugate vaccines in adolescents and in people at persistently high risk of meningococcal disease (e.g. asplenia, complement deficiency)
What is the recommended vaccination schedule for normal patients in regards to the vaccination against meningococcus?
11-12, then booster at age 16 (right before college!)
How does idiopathic pulmonary hemorrhage present?
Repeat episodes of pulmonary infiltrates associated wtih anemia and hemoptysis
PHYS: milk allergy possibly
Framework Question: How to think or characterize Spinal Muscular Atrophy to better make sense of the presentation?
Spinal Muscular Atrophy
“Muscular atrophy” occurs because of “spinal” cause, that is, neurodegeneration of the anterior horn cells.
Hence, presentation is ALL lower motor neuron: areflexia, hypotonia, flaccid paralysis, fasciculations
Difference between SMA 1, 2, 3
SMA 1: diagnosed < 6 mos, never sits
SMA 2: diagnosed between 6-18 months, sits, but never walks
SMA 3: Diagnosed > 18 mos, walks, but falls
Describe how the presence of the XX chromosome vs the XY chromosome leads to female and male genitalia respectively.
In the process of normal sex differentiation, the gonads and internal and external structures begin as bipotential. The sex determining region (SRY) and other genes on the Y chromosome are responsible for gonadal differentiation into a testis.
TIP: srY is located on the Y chromosome
In the presence of SRY gene, testicular Leydig cells secrete testosterone and Sertoli cells secrete anti-Müllerian hormone (AMH). The testosterone stabilizes the Wolffian ducts, which become the epididymis, vas deferens, seminal vesicles, and ejaculatory ducts. Anti-Müllerian hormone causes the Müllerian structures to regress. The Müllerian structures are the uterus, fallopian tubes, cervix, and upper vagina. Testosterone is converted to the more potent androgen, DHT, by 5α-reductase. Dihydrotestosterone is responsible for virilizing the external genitalia, causing growth of the phallus, fusion of the labioscrotal folds, and migration of the urethra to its normal position in the penis.
What hormone is responsible for virilization of genitalia?
Testosterone is converted to the more potent androgen, DHT, by 5α-reductase. Dihydrotestosterone is responsible for virilizing the external genitalia, causing growth of the phallus, fusion of the labioscrotal folds, and migration of the urethra to its normal position in the penis
What physical exam findings on a newborn is highly indicative of XY chromosomes?
Palpable gonads
During what part of resuscitation (PALS) should access be obtained?
First 2 minutes of CPR - AKA the first round of CPR. If no IV, then move to IO.
CPR being performed: what is the fastest way of obtaining access - PIV, IO or Central line?
IO
” In a large meta-analysis, the IO route achieved more frequent successful access and improved time to achieving access as compared to peripheral and central venous techniques in patients requiring emergent vascular access in the emergency department.”
What physical exam finding is consistent with hepatomegaly in neonate? Children?
> 3.5 cm liver edge below the right costal margin
> 2cm in children
Patient with hip pain. What type of radiographs to order?
Anteroposterior view of the pelvis and a “frog leg” lateral view of the hip.
Radiograph demonstrates Legg Calve Perthes disease. Next step?
Crutches and non-weight bearing, referral to Ortho. The key is to maintain the femoral head in the acetabulum. In order to do so, non-weight bearing to keep from persistent strain
Explain to a patient what an advanced directive is.
Advance directives, also known as “living wills”, outline patient’s wishes for medical treatment in event of lost decision-making capacity.
This does include end of life care, but is not limited to that.
At what age is DEET safe for a child?
2 months! Super early!
What percent DEET is sufficient?
30% is sufficient. More than that yields no added benefit.
TIP: protection from BOTH ticks and mosquitoes! Didn’t know that!
What is the definition of “elevated blood pressure” vs “Stage 1 HTN” vs “Stage 2 HTN” in pediatrics?
The updated definition and stages of hypertension are:
- normal BP (< 90th percentile)
- elevated BP (≥ 90th percentile to < 95th percentile);
- stage 1 hypertension (≥ 95th percentile to <95th percentile + 12 mm Hg)
- stage 2 hypertension (≥ 95th percentile + 12 mm Hg).
What is “dual protection” in regards to contraception?
Condoms + another method of contraception to prevent BOTH pregnancy and STI’s
What amount of cow’s milk intake places toddlers at risk for IDA?
> 32 ounces of milk
COOL PHYS:
- Low BA of iron
- The induction of an exudative enteropathy with associated mucosal injury and persistent enteric blood loss not associated with gross bleeding
Explain expected RDW and TIBC in IDA
The RDW is a measure of the variability of red blood cell volume. As the production of hemoglobin becomes more unreliable when iron levels fall, the variability of red blood cell sizes increases, as represented by an increased RDW. The TIBC is a measure of the blood’s capacity to bind iron with transferrin. As the iron concentration falls, the capacity to bind iron increases, and thus the TIBC increases.
RDW - red cell distribution width
What is the treatment of choice for JIA with low disease activity?
NSAID!
TIP: few rheumatologic diseases can be treated with NSAIDS alone
What is the diagnosis of JIA?
“4 + 5 + 6 ~ 16” Rule
< 16 years old - “Juvenile”
4 Joints = oligo
5 joints = poly
> 6 weeks of persistent sx
What is the reccommeded treatment of JIA with moderate to severe disease?
MTX
TIP: Just like RA! Used to be called JRA.
What is the difference between phimosis and paraphimosis?
Phimosis is the inability to retract the foreskin
Paraphimosis is the opposite, that is, after retraction, you can’t reduce the foreskin
- Paraphimosis is an EMERGENCY due to ischemia
By what age will most phimosis resolve for most boys?
90% by age 3
99% by adolescence
How do disorders of sex development present in infancy? (DSD) AKA What presentations should suggest an underlying DSD?
DSD presents in 2 ways:
1) Ambiguous genitalia - neither fully male in appearance nor fully female in appearance
2) Discordant genotype/phenotype sex:
- Ex: XY prenatally, but undervirilized genitalia at birth (micropenis)
- Ex: XX prenatally, but virilized genitalia (clitoromegaly)
Framework question:
What is considered disorders of sex development (DSD)?
A group of congenital conditions in which the development of chromosome, gonad or anatomic sex (external genitalia) is atypical. And any combination of the three.
Framework question:
What are broad ways to categorize DSD?
Categorize by the chromosomes:
- 46 XX DSD - females with virilization
- 46 XY DSD - males with undervirilization
- DSD with sex chromosome abnormalities - e.g. Klinefelter in which XXY w/ undervirilization
What type of temperament is a risk factor for anxiety disorder in children?
Behavioral inhibition
What does MELAS stand for?
Mitochondrial Encephalomyopathy Lactic Acidosis with Stroke-like symptoms
Framework Question:
What organs tend to be involved in mitochondrial disorders?
Organs highly dependent on aerobic metabolism:
- Heart
- Muscles
- Nervous system
What is the inheritance pattern of mitochondrial disorders?
“Maternal inheritance” which means the disorder is transmitted from the mother. This is the case since ALL mitochondrial DNA comes from mothers.
Framework Question:
Why is the presentation of MELAS extremely variable?
A woman can transmit a variable amount of mutated mtDNA to each of her offspring, thus yielding significant clinical variability among her children, the “bottleneck effect.” In addition, tissue distribution can vary among organ systems, a concept known as “heteroplasmy.” Because of heteroplasmy, a mtDNA pathogenic variant may not be detectable in leukocytes, thus warranting molecular genetic testing of mtDNA in other tissues, such as cultured skin fibroblasts or skeletal muscle for diagnosis.
Menke Syndrome PICMONIC
- Copper transport defect: Copper monkey riding a copper roller coaster ride
- Kinky, twisted hair - Corkscrew looking hair
- Neurologic/Connective tissue/Bone manifestations are the most commonly affected organs
- Neurologic manifestations include seizures
- Connective tissue defects include saggy skin and abnormal blood vessels
- Bone manifestations include: osteopenia, long bone fractures
- X linked
- Death by 3 years of age
Copper monkey with kinky hair in a transporter, bowling with a clear ball with brain inside, aiming at skeleton bones (instead of bowling pins) and X marks the spot for all the bones
Child exposed to patient with proven measles. Next step in management?
Depends if they are fully vaccinated. If < 2 vaccines, then administer MMR vaccine within 72 hours
TIP: HIGHLY contagious, that is, 90% of exposed patients will contract measles
When is MMR vaccination recommended?
The first dose of MMR is recommended at 12 to 15 months of age, and the second dose is recommended between 4 to 6 years of age.
Newborn is born with no prenatal care and gestational age is unknown. What are physical exam findings consistent with late pre term (34-36 weeks)?
- Breast development will show a stippled areola with 1- to 2-mm breast bud
- Movements of the arms may be characterized as jerky but not irregular
- They may exhibit periodic breathing. However, they should not have periods of apnea (cessation of breathing for 20 seconds)
- Their ear cartilage should be soft with instant recoil
What are some associated risk factors for the development of persistent asthma?
- Obesity
- Vitamin D deficiency
- Allergies
Most common type of presentation for Bacillus Anthracis?
Cutaneous anthrax
TIP: Pulmonary anthrax has a mortality rate as high as 90%. But this only occurs if bacillus anthracis is aerosolized, something that occurs in bioterrorism
Neonate with severe pulmonic stenosis. Next step?
- Neonates with severe pulmonary stenosis should urgently undergo balloon valvuloplasty, and therefore be transferred as soon as possible to a center that performs such procedures regularly. With severe pulmonary stenosis, the right ventricle can ultimately fail because of the increased work needed for pulmonary blood flow in the context of a high pressure gradient.
- If O2 sat is abnormal, prostaglandin infusion to keep PDA open
Vitamin deficiency associated with biliary atresia?
ADEK given abnormal biliary flow
Vitamin deficiency associated with biliary atresia?
ADEK given abnormal biliary flow
Framework question:
What is the difference between minimal, moderate, deep sedation and general anesthesia?
The level of sedation is characterized by patient’s ability to respond, the effect of the medication on the respiratory/circulatory system/airway.
E.g.
- Moderate sedation: purposeful response to verbal commands with or without gentle stimulation, maintenance of cardiovascular function, spontaneous ventilation, and no required intervention for airway maintenance
- Deep sedation: INTUBATED; interventions may be required to maintain the airway and ventilation, cardiovascular function is usually maintained, and purposeful response will occur after repeated stimulation.
When is insulin recommended for youth’s with Type II DM?
The American Diabetes Association recommends that insulin should be initiated at diagnosis for youth with type 2 diabetes if the blood glucose is greater than or equal to 250 mg/dL (13.9 mmol/L) or hemoglobin A1c is greater than or equal to 8.5%
Framework Question:
What is the progression of the understanding of rules/right/wrong for toddlers/preschoolers to early school age children to to school age children?
- 2-4 year olds do not have a concept of rules and ownership
- early school age: understand wrong though they have difficulty fighting the impulse to steal
- school age children: around 8 develop a conscience and aware of rules/expectations
At what size does an ovarian cyst require gynecological consultation?
> 6cm
What is the cause of a “simple ovarian cyst”?
Simple cysts result from mature ovarian follicles that did not ovulate and failed to involute.
What is the difference between a “Simple Ovarian Cyst” and a “Luteal Cyst”?
- Simple cysts come from mature follicles that fail to ovulate and fail to involute thereafter. Luteal cysts come from follicles that ovulate, but fail to involute.
- Can only be distinguished by US. Luteal cysts has “echoes”
What signs should suggest the presence of shock in a child (not including hypotension)?
Shock should be suspected with tachycardia and poor perfusion even without hypotension, as it is often a late finding.
What is the recommended fluid resuscitation for adults in septic shock? Children?
- Adults: 30ml/kg within the first 3 hours
- Children: 20ml/kg boluses, repeat up to 60ml/kg
After what period of time does a newborn’s creatinine, as obtained by lab, reflect his/her normal creatinine and not that of his/her mother?
2 weeks
Framework Question:
What age do children reach adult levels of GFR?
2 years old
TIP: 2 year old > term infant > preterm infant GFR (full renal embriogenesis occurs at 35 weeks, so a 32 weeker hasn’t even fully developed his kidneys). Hence, GFR is lower at younger gestation. And lower at birth.
Why are children/adolescents at higher risk of hypercalcemia due to immobility compared to adults?
Children and adolescents are at higher risk than adults for hypercalcemia during immobilization because of the high bone turnover state normally seen in these age groups.
When is it usually recommended that solid organ transplant patients receive their vaccinations - pre or post transplant?
Although pediatric SOT candidates may have a decreased immune response to vaccines compared with healthy children, they are more likely to develop vaccine-induced immunity than SOT recipients receiving post-transplant immunosuppressive agents.
Patient is 7 years old and will be receiving a renal transplant soon. He has NOT received any PCV13 or PPSV23. What vaccinations should he receive?
In children aged 6 through 18 years at high risk of pneumococcal disease who have not received any doses of PCV13 or PPSV23, administration of 1 dose of PCV13 followed by 1 dose of PPSV23 at least 8 weeks later and a second dose of PPSV23 5 years after the first is recommended.
TIP: PCV 13 ALWAYS comes before PPSV23
What is the prevalence of reflux in preterm infants?
UNIVERSAL
What is the recommended agent to thicken formula?
Oatmeal since rice cereal carries the risk of Arsenic poisoning
What is the next step of treatment for preterm infant with persistent GER despite non-pharm techniques?
Extensively hydrolyzed formula or thicken feeds with oatmeal
PHYS: reduced transit time
What is the treatment of choice for Klinefelter patients with for their hypogonad state?
Testosterone replacement
When is mefloquine contraindicated?
In individuals with active or recent history of a major psychiatric disorder, including depression, anxiety, psychosis, or schizophrenia, because use of the drug can lead to psychoses and other psychiatric symptoms.
When is primaquine contraindicated?
It should not be used in individuals with glucose-6-phosphate dehydrogenase deficiency because it can cause hemolytic anemia.
When is Atovaquone-proguanil contraindicated?
Breast feeding mothers and renal dysfunction
What are alternative prophylaxis for Plasmodium Falciparum if chloroquine is not available or resistance is a concern?
Atovaquone-proguanil
Doxycycline
Mefloquine
TIP: Like chloroQUINE, they have similar endings except Atovaquone
What is the recurrence of congenital diaphragmatic hernia in patients with CDH s/p repair?
Up to 50%
Hence, recommendation of yearly CXR until 16
How many doses of DTaP should a child receive before age 7?
5: 2,4,6 mos, 15-18 mos, then 4-6 yo
Then Tdap at 11-12 yo
Pediatric patient is getting catch up vaccines for TDaP. What is the interval between his first TDaP and second one?
4 weeks
What are the clinical criteria to help distinguish a viral sinusitis vs a bacterial sinusitis?
Any of the 3:
1) > 10 days of symptoms
2) Worsening of symptoms after an initial improvement of symptoms
3) 3 days of severe symptoms at the onset of illness
What is Posterior Urethral Valve?
Posterior urethral valve is a condition caused by obstructing membranous folds in the posterior urethra
Framework Question:
How does obstructive uropathy present depending on the level of obstruction?
PUV: Bilateral hydroureteronephrosis
UVJ: Unilateral hydroureteronephrosis
UPJ: Unilateral hydronephrosis with normal ureter dilation
What is the definition of status epilepticus?
> 5 minutes of seizure activity
What is first line treatment for status epilepticus?
Ativan: 0.1mg/kg IV (max: 4mg)
Midazolam: 0.2 mg/kg IM (max: 10mg)
Diazepam: 10mg rectal or 0.1mg/kg IV (max: 10mg)
Framework question:
What nutritional deficiencies are affected depending on the part of bowel removed?
Proximal small bowel: iron, Vit D and Folate
Distal small bowel (ileum): B12, bile salt absorption
What is the recommended post-exposure prophylaxis for rabies?
- Rabies immunoglobulin and rabies vaccine on day 0
- Rabies vaccine on day 3, 7, 14
Interesting presentation of rabies
Ascending paralysis
What animals, if bitten by, are considered rabid?
Foxes, bats, skunks, racoons and wood chucks
Most common cause of hyperthyroidism in adolescents?
Graves disease
What antibodies are associated with Graves vs Hashimoto’s?
Graves: Thyrotropin Ab (that is, Ab to the TSH receptor)
Hashimoto’s: Anti TPO Ab
What is the relationship between HCG and hyperthyroidism?
HCG is similar to TSH, hence, can bind to the TSH receptor and cause hyperthyroidism E.g. molar pregnancy.
Can inhaled corticosteroids lead to long term effects on linear growth?
Inhaled corticosteroids have no adverse effect on long-term growth in children. However, poorly controlled asthma can affect growth, as can many other factors.
How to diagnosed head lice?
Gold standard: Head lice infestation is diagnosed by finding live lice on the scalp or eggs attached to hairs that likely are viable (darker in color and located ≤ 1 cm from the scalp)
What are findings on PE of successfully treated head lice?
No lice White eggs (empty eggs) > 1 cm away from scalp
COOL: Eggs are attached to hairs (within 4 mm of the scalp). Viable eggs are pigmented to match the color of surrounding hair. In contrast, empty eggs (ie, those that have hatched) appear white. Eggs are incubated by the host’s body heat and hatch in 8 to 9 days (range, 7-12 days). Based on this information and the knowledge that scalp hair grows approximately 2.5 mm/wk, eggs located more than 1 cm from the scalp likely have hatched.
What is first line therapy for head lice?
1% Permethrin on day 1 then day 10
Adolescent shares that he is smoking E-cigarettes because it is safer than cigarettes. Your response?
Electronic-cigarette use is associated with an increased risk of cigarette smoking. Meta-analysis has confirmed that e-cigarette use is associated with an increased risk of cigarette smoking.
The use of tobacco and nicotine-containing products is also associated with an increased risk of using drugs like marijuana
