Pediatric Disorders Flashcards
Fever without a source
Temp of 100.4 or greater, <96.5, no discernible infection, non-toxic appearance, abrupt onset, <7 days duration
•Age 0-3 months: Admit for CBC with diff, CMP, UA & culture, CSF analysis and culture
•Age 3-36 months, similar workup, but may be managed outpatient if the infant is well appearing.
•If toxic appearing, add HSV workup
Fever of Unknown Origin
Fever> 101.9 for at least 8 days without identified cause. Routine labs have not revealed a source.
- Stop all nonessential medications
- Comprehensive history: Ethnicity. Travel, exposure to animals, insects, risks for HIV, TB, dental health, immunization status
- PE Vital signs, eyes, ears, lymph, lung sounds, cardiac sounds, hepatosplenomegaly, Joints, bones, skin, perianal/rectal
- Diagnostics: *CBC w diff, *CMP, *UA & culture, If toxic looking, add blood cultures serial if suspicious of endocarditis), CSF, *ESR/CRP, *viral cultures (infectious cause), uric acid, LDH, peripheral smear (oncologic source) consider TSH & FT4, ANA, RF, complement, ESR/CRP, ferritin (Autoimmune/Inflammatory), Immunoglobins, lymphocyte markers, antibody titers (immunocompromised)
- CXR, EKG if suspicious of endocarditis
- 30% infectious, 20% autoimmune, 10% oncologic, 5% drug fever (can be caused by acetaminophen, NSAIDS)
*Early testing and assessment can be done in primary care before 8 days, if no identifiable source, admit for further testing
Endocarditis
(Inner lining)
LP- Post CHD Repair
CP- Prolonged fever, rigors, diaphoresis, fatigue, weakness, arthralgias, myalgias, weight loss
A/D- EKG abnormalities, Duke criteria, CBC, BMP, UA, blood cultures, EKG, Echo
T- Pay attention to prolonged fever, Admit for diagnostics, care is antibiotic therapy and supportive to avoid CHF
Myocarditis
(Inflammation of the heart muscle)
LP-Recent infection (viral/bacterial/parasitic/fungal, can be GI infection.
CP-Autoimmune disorders, drug use Shortness of breath, vomiting. abdominal pain, poor feeding,
hypoperfusion
A-Lymphadenopathy, rales, S3 and/or pericardial friction rub, EKG abnormalities (tachycardia, other arrhythmias), hypotension, hepatomegaly
D- EKG, cardiac enzymes, BNP, CXR. Frequently misdiagnosed
T-Admit for diagnostics and supportive cardiac therapy. Other tx is focused on cause.
Pericarditis
(Inflammation of the outer lining of the heart)
LP: Previous infection, autoimmune disorders, trauma, med ADR, likely underdiagnosed and reported.
CP: Classic triad: CP (key element), dyspnea, fever. CP worse with leaning backward, deep breaths, or coughing. Misdiagnosed as pneumonia
A/D: EKG – concave ST elevation, Cardiac ultrasound, CXR (less helpful) No specific labs, but troponin, ESR/CRP elevations, CBC, blood cultures,
T: Admit for diagnostics and supportive cardiac therapy, anti-inflammatory treatment (NSAIDS, glucocorticoids) ABX if infection present.
Kawasaki’s Disease
LP: Ages 3 mos. To 4 years, Asian ancestry
CP: Fever >5 days, polymorphous rash, oral mucositis, bilateral conjunctivitis, erythema of hands/feet, strawberry tongue
A/D: Cervical lymphadenopathy, later stages can include arthralgias, peeling skin (hands, feet) abdominal pain, diarrhea, vomiting,
CBC, ESR/CRP, Echo
T: Admit for diagnostics and supportive cardiac therapy single infusion of intravenous immune globulin (IVIG)
Rheumatic Fever
LP: Indigenous populations, overcrowded living conditions, poverty, peak incidence 5-15 years
CP: Recent sore throat, fever, joint pain
A/D: Chest pain, palpitations, shortness of breath, new murmur, arthritis, chorea, erythema marginatum, and subcutaneous nodules, see Jones criteria in MDCALC
T: Admit: Once dx is confirmed, anti-inflammatory agents
Viral Pharyngitis
LP: sick contact
CP: Sore throat, nasal congestion, cough, nausea, vomiting, abdominal pain
A/D: Check immunization status
T: Analgesics, saltwater gargle, maybe topical anesthetics
Strep Pharyngitis
LP: sick contact, children and adolescents
CP: Sore throat without nasal congestion, cough, nausea, vomiting, abdominal pain
A/D: Pharyngeal exudate, painful anterior cervical lymphadenopathy (consider gonorrhea, chlamydia, HIV – signs of sexual abuse) , scarlatiniform rash in Strep.
Rapid antigen test for strep, If negative but clinical presentation suggests bacterial, throat culture, Monospot
T: Beta lactams: Pen G, Amoxicillin
Teething
LP: Between 6 and 12 months, all teeth erupted by 36 months
CP: Irritability, loss of appetite, difficulty sleeping, drooling.
A/D: None
T: cold (but not frozen) hard rubber teething rings, rubbing the gums with a clean finger , no gels, creams, ETOH for pain recommended. No liquid filled teething rings. Analgesics (not ASA)
Tonsilloliths
LP: After age 20 years, uncommon in children
CP: Sore throat, bad breath, sensation of a foreign body, earache
A/D: Friable or hard solidifications in tonsillar pillars. Clinical diagnosis, but CT could detect stones not outwardly visible Good dental hygiene, saltwater gargles, careful removal with cotton swab
Otitis Media
LP: Most commonly 6-24 months, commonly preceded by a URI
CP: Acute onset, ear pain, irritability
A/D: Bulging TM, poor mobility with pneumatic otoscopy, TM may be yellow, pink, red, but red alone is not diagnostic.
T: Most are viral, analgesics are first line. AOM is most common cause of inappropriate abx, Amoxicillin is first line, although Augmentin can be considered.
<6 mos. Treat with 10-day course
>6 mos. can have analgesics with a watch and wait for 48-72 hours.
Under 2 years, 10 days duration, 2 – 5 years, 7-day duration, >6 years, 5–7-day duration.
Measles
LP: Unvaccinated status, exposure to measles
CP: Fever, cough, runny nose, sore throat, conjunctivitis
A/D: Maculopapular rash, beginning on head, Koplik spots (Red spots with a bluish-white central dot on erythematous buccal mucosa)
IgG/IgM ELISA or PCR
T:Antipyretics/analgesics, supportive, consider Vit A supplementation in children <2 or who have a severe case
Scarlet Fever
LP: 4-8 years
CP: Fever, malaise, sore throat Lymphadenopathy, swollen red tongue, HA, nausea, vomiting, sandpapery rash that starts at ears, moves down trunk and then to extremities. Red streaks in body folds (Pastia lines). Dx’d with rapid strep antigen or with culture
T: Associated with group A strep. Beta-lactam x 10 days. Antipyretics/analgesics, hydration, antihistamines for itching rash
Rubella
LP: Unvaccinated status, exposure
CP: Slight fever, sore throat, runny nose and malaise
A/D: Petechiae on palate and uvula, post auricular, occipital, posterior cervical lymphadenopathy, rash with pink/light red spots beginning on face and spreading to neck, trunk, extremities. Dx IgM/IgG serology,
T: Self-limiting and mild, no treatment necessary except for pregnant women, pregnancy follow up and counseling
Erythema Infectiosum (5th) Parvovirus
LP: Young children, family clusters
CP: Mild fever, headache, can be vague viral symptoms or asymptomatic
A/D: Firm and red cheeks with burning sensation followed by a diffuse lacy rash.
Dx Parvovirus PCR or IgG/IgM serology
T: Usually mild and self-limiting, pregnant women may have complications, follow up and counseling
Roseola
LP: < 2 years
CP: High fever (3-7 days) days), followed by pink macules and papules (2-3 days)
A/D: Erythematous TM, lymphadenopathy (cervical and post auricular). Clinical diagnosis
T: Antipyretics and hydration
Varicella
LP:Unvaccinated status, children 1-9 years
CP: Fever, vesicular rash, mucosal vesicles
A/D: Pruritis, HA, fatigue, sore throat, tachycardia. Clinical diagnosis, but can do PCR testing
T: Acetaminophen (no NSAIDS), antihistamines, IV antiviral therapy for compromised patients, severe cases
Herpes 1 & 2
LP: Immunocompromise, sexual practices,
CP: Vesicles developing into painful ulcers (genital/oral)
A/D: Dysuria, lymphadenopathy, fever,
Dx with viral culture, HSV PCR
T: Oral antivirals for both episodic and suppressant therapies
Cytomegalovirus
LP: Immunocompromise
CP: Generally asymptomatic in immunocompetent individuals.
A/D: If symptomatic, malaise, fever, NVD, visual disturbances. CBC, CMP, Confirmatory test CMV IgM acute illness, CMV IgG past exposure
T: Generally self-limiting, counselling with pregnant women, severely teratogenic, refer immunocompromised patients
Epstein virus
Mononucleosis
LP: None
CP: Fever, pharyngitis, lymphadenopathy, posterior cervical is a key finding
A/D: May be splenomegaly, rash, jaundice, myalgia. CBC, EBV antibodies, Monospot, LFT
T: Rest (controversial), good hydration, antipyretics, and analgesics, Restrict from physical activity 2-4 weeks after infection (confirm resolution of splenomegaly prior to activities)
Molluscum Contagiosum
LP: Common, close contacts
CP: Smooth, pearly papules, pruritis, accompanying dermatitis
A/D: Facial or groin distribution of lesions. Clinical dx, dermoscopy or biopsy can be used to confirm.
T: Self-limiting in immunocompetent patients, Limited evidence for salicylic acid, benzoyl peroxide, and tretinoin, cryotherapy. Refer immunocompromised patients or those with possibility of facial scarring
Coxsackie
Hand, foot, mouth disease
LP: < 10 years
CP: Low grade fever, oral vesicles, rash or vesicles on hands and feet
A/D: Malaise, anorexia, sore throat, abdominal pain, diarrhea, cough
Clinical diagnosis, can also do CBC, viral culture
T: Generally self-limiting, analgesics, topical anesthetics
Mumps
LP: Unvaccinated status
CP: Swelling/pain of parotid glands
A/D: Constitutional symptoms, orchitis, oophoritis. Clinical diagnosis, but can do viral culture of saliva, CBC, antigen PCR, antibodies,
T:Supportive care with hydration, analgesics, antipyretics
Hyperthyroidism (Grave’s Disease)
LP: Peak incidence 10-15 years
CP: Same as adult – nervousness, weight loss, heat intolerance, tachycardia, tremor
A/D: Enlarged thyroid, TSH, FT4, iodine uptake scan, autoantibodies
T: Referral endocrinology, beta blocker for symptom relief, 6-month follow-up
Hypothyroidism
(Hashimoto’s disease)
LP: Congenital or acquired (Hashimoto’s disease)
CP: Same as adult – weight gain, lethargy, cold intolerance, can be subclinical or nonspecific symptoms, delayed development, short stature
A/D: can be subclinical delayed development, short stature. Enlarged thyroid, TSH, FT4.
Consider antithyroid peroxidase antibodies, lipid panel, CBC, thyroid scan
T: Thyroid replacement therapy
Insulin Dependent Diabetes
LP: Any age, peak 10-14 years, family history
CP: Polyuria, polydipsia, weight loss, and weakness.
A/D: Blurred vision, N&V, abdominal pain,
Dx: random, fasting glucose, HbA1c, consider fasting C-peptide, autoimmune markers
T: Referral endocrinology, basal bolus insulin regimen, diet management, activity management, self-monitoring blood glucose
Anabolic Steroid Use
LP: Male, history of sports/physical activity, hx of dysmorphic disorder
CP: History of increased appetite/food consumption, rapid weight gain increased muscular build.
Chronic use can result in dermatologic, psychiatric, sexual effects.
A/D: May not seek treatment for steroid use specifically, maintain high level of suspicion. Acne, hirsutism & menstrual irregularities(females), scrotal pain, higher pitched voice (males), hostility, aggression, irritability, labile mood
Urine toxicology, urinary ratio of testosterone glucuronide to epitestosterone glucuronide. FH, FSH, CBC, CMP, lipid panel, hepatitis panel, HIV, CK
T: Manage complications of withdrawal, counseling, psychotherapy, nutrition counseling. Assess for other substance abuse. Consider referrals to mental health, endocrine, cardiac or other professionals depending on effects and comorbidities
PCOS
LP: Symptoms begin at puberty, family history, obesity
CP: Irregular menstruation, hirsutism
A/D: Serum 17 hydroxyprogesterone, prolactin, TSH, glucose tolerance, lipid panel, consider total and free testosterone, LT< FSH, ultrasound, basal body temperature.
T: Desiring fertility: weight loss, metformin adjunct
Not desiring fertility
OCP, metformin adjunct
Asthma Severity Rating
