Pediatrics 1 Flashcards
Uniqueness of the physical exam: you have ____ patients
2! the child and the parent
Uniqueness of the physical exam: the manner in which you examine the chid will vary based on their ____
age
Uniqueness of the physical exam: the child’s behavior will depend on where they are _____
developmentally
Uniqueness of the physical exam: vital signs include…
percentiles of:
height
weight
head circumference
Uniqueness of the physical exam: based on age of the patient, there will be unique ____ to examine and specific ______ to perform
body parts
maneuvers
When thinking about what to expect on PE, kids under ____ should be happy, smiling unless hungry or have a dirty diaper
6 months
When does stranger anxiety begin?
6 months
When does separation anxiety begin?
9 months
What can you expect when a 9 month old is taken from the parent?
a high-pitched, sustained vocal response
How long do stranger and separation anxiety persist?
toddler age group- 2 years and older
Changing the PE approach based on age: 0-6 months
proceed with traditional HtT exam
Changing the PE approach based on age >6 months when there is stranger and separation anxiety (5 tips)
- DON’T begin by examining the head/ears/nose/throat
- DON’T examine the child on the examining table
- Examine the child while in the parent’s lap
- BEGIN the exam with the least anxiety-provoking area, usually start with the chest and abdomen
- Do the head and neck exam LAST, end the exam with the ears followed by the throat
Should you immediately place the stethoscope on the child?
no, have the child first hold the auscultation end of the stethoscope to become familiar and have a penlight, small toy, etc that they can be distracted with
Are your parents useful in the exam?
Yes, they’re your ally
On the newborn and infant exam, how should you proceed?
start with what the baby gives you
if the baby is quiet, start with the heart and lung exam
What percent of children have an innocent heart murmur on physical exam?
50%
what are you inspecting for on the CV exam?
- skin color
- pallor, cyanosis, plethora (polycythemia)?
- chest wall movement.. heaves, symmetry
How do you assess vasculature on the CV exam?
- check cap refill
- palpate brachial and femoral pulses
- Assess for brachio-femoral delay
What is brachio-femoral delay an indication of?
coarctation of the aorta
or
aortic stenosis
LIFE THREATENING, no blood getting to the body
When does brachio-femoral delay manifest?
1-2 weeks
what is plethora/polycythemia?
too many RBCs causes a ruddy (reddish purple) complexion
4 places to auscultate on CV exam
RUSB
LUSB
LLSB
apex
In newborns, you also auscultate on the back for ____
peripheral pulmonary branch stenosis
What is peripheral pulmonary branch stenosis?
stenosis where the pulmonary artery bifurcates
what does peripheral pulmonary branch stenosis sound like on auscultation?
high-pitched whoosh… sounds will echo equally to both lung fields
What can you do if the child is crying on CV exam? (we need a quiet room)
give them something to suck on
take your time
name 2 challenges on the CV exam
- lung sounds often sound like heart sounds
- rate: infants have a baseline rate in the 100s
What’s special about the patient’s position in a pediatric CV exam?
MUST examine in both supine and and upright
Why examine peds supine and upright on CV exam???
Normal heart sounds when sitting up, but systolic murmur when lying down is normal.
What do you expect to hear differently between sitting up and laying down on CV auscultation?
As blood comes back to the hear, the venous return is impacting the murmur..
Sitting up: VR is reduced, murmur is decreased
Laying down: VR is increased, murmur is pronounced
What would you hear if there is Hypertrophic Obstructive Cardiomyopathy (HOCM)?
Opposite of a normal heart murmur..
Sitting up: murmur increased
Laying down: murmur decreased
What are you observing for on the Lung/Thorax exam?
- RR and effort, chest wall movement
- Manifestations of respiratory distress
What are manifestations of respiratory distress?
- nasal flaring
- tracheal “tag”
- sternal retractions
- subcostal retractions
- paradoxical movement between chest and abdomen, “see saw” respirations
What are “see saw” respirations?
Normally, when we breathe in, the chest AND abdomen expand. With these, the chest expands, the abdomen sucks in.
This is due to diaphragmatic fatigue and use of the abdominals to compensate
What should you think about if you see “see saw” respirations?
the patient is on the verge of respiratory failure and need of intubation!
2 tips for auscultating the lungs
- coughing or crying is an excellent opportunity to listen to the lungs
- hold your finger in front of the child and have them imagine it is a candle, then ask them to blow it out
What’s different about a pediatric abdominal exam?
compared to adults, the liver and spleen are easily palpable
If you feel a kidney on abdominal palpation, what do you do and what should you be thinking about?
Mention it!!
Wilm’s Tumor
What should you pay close attention to on a newborn abdominal exam?
the umbilicus and umbilical cord remnant
Abdominal exam findings: diastasis rectus
abdominal fascial is weak, and the abdomen protrudes
a very common variant, nothing to do!
Abdominal exam findings: umbilical hernia
common benign finding in infants and toddlers
nothing to do unless it persists beyond 4 years old
Abdominal exam findings: linea nigra
a line running midline from the umbilicus to the suprapubic area
GU exam positioning
frog leg posture
on parent’s lap or on the exam table
Describe the male GU exam
- inspect urethral opening, foreskin, shaft
- if uncircumcised, DO NOT forcefully retract the foreskin, only retract enough to visualize the urethral opening to make sure there’s no hyper or hypospadias
- palpate for BOTH testicles
Describe the female GU exam
inspect labia, clitoris, urethral opening, and external vaginal vault
What are you looking for on anus inspection?
patency
What are you assessing for on a newborn MSK exam and how do you do so?
hip dysplasia
compare gluteal folds and skin folds of right and left legs
perform Barlow and Ortolani maneuvers
What else do you look for on MSK exam?
deformities, hypermobility of joints, instability, curvature of spine
What are you observing for on eye exam?
alignment of eyes via corneal light reflex
strabismus=misalignment of the eyes
EOMs
Other than the corneal light reflex, what other test do you do on the eye exam?
red reflex
Infants generally don’t demonstrate sustained tracking until approximately ____ of age
12 weeks
When does vision become 20/20?
3 years
How do you perform red reflex?
- be sure to encircle both eyes with the light
- compare left and right eyes at the same time
- may need to turn off lights with newborns and infants
- try to avoid prying the eyes open with your hands
What is leukocoria?
white cornea instead of red on when the red reflex is performed
What are you looking for on inspection during ear exam?
skin tags preauricular pits abnormally shaped pinna ear "set" symmetry/asymmetry
What’s significant about ear development and what we think of when we see abnormalities on inspection?
the kidneys develop at the same time as the ear… abnormalities of the ears can pint to kidney issues»_space;> get kidney US
How to hold the otoscope with the insufflator bulb
- hold otoscope in dominant hand with bulb in the palm
- Use the other hand to gently pull the pinna posteriorly
How to position the patient for an ear exam
- in the parents lap
- one hand holding head, one hand across the child’s body holding their arm
- child’s other arm is under, behind the parent’s back
What if there is wax?
- try to clean it out, under the supervision f a resident or attending (a skill worth perfecting)
- if wax looks dried, it can be harder to remove… may have become dried due to the canal lining, hence causing pain/bleeding on attempted removal
- soft, “wet” appearing wax is easier to remove
How to use a tongue blade in toddlers
insert blade along the side of the mouth, move posteriorly, then gag the child
What are you inspecting for in the oral exam?
Size and color of the tonsils
oral dentition and palate
tongue and gums for any lesion
In newborns and young infants, you need to exam the oral cavity by _____
inserting a gloved finger to assess palate and strength of suck
What do you palpate for on head exam?
fontanelles, anterior and posterior (MC vital sign that’s mis-measured)
suture lines
What do you inspect for on head exam?
asymmetry
abnormalities
what are common abnormalities on head exam?
cephalohematoma
caput succedaneum
overriding sutures
molding
when do you stop measuring FOC?
after 24 months
Importance of a skin exam
newborns and infants have many common skin findings- become familiar with as many as possible
BUT, skin findings in infants can be a harbinger of neurologic disease… remember that the ectoderm develops into the neurologic systems and the skin. Find out which diseases these findings can be a sign of.
Cafe-au-lait spots are associated with
neurofibromatosis
Ashley spots are associated with
tubosclerosis
Ear is to kidney as
Skin is to ____
nervous system
When do you perform developmental exams?
during well child visits or if there is concern regarding child’s development
What’s included in a neuro exam?
toddler/school aged children: similar to adult exam, mostly observation of coordination, gait, motor skills
infants: encompassed within other parts of the physical, but also includes assessment of primitive reflexes
CN II, III, IV, VI assessment
fixing/following, absence of ptosis
CN V assessment
rooting reflex
CN VII assessment
symmetric facial expressions during cry or smile
CN VIII assessment
startles to noise
CN IX,X assessment
suck, gag reflex
CN XI assessment
symmetric movement of UEs
CN XII
symmetric tongue
6 solid tumors unique to children
neuroblastoma retinoblastoma wilms' tumor rhabdomyosarcoma osteosarcoma ewings sarcoma
_____ is the fourth most common type of cancer in children
neuroblastoma
MC malignancy in infants
neuroblastoma
MC extracranial solid tumor of childhood
neuroblastoma
Neuroblastoma is MC in
sex:
age:
race:
male: female 1.2:1
2 years
white > black/hispanic
Neuroblastoma develops from ______ cells normally found in the_______ and _____
neural crest cells;
sympathetic ganglia, adrenal medulla
____ can be described as a solid mass with areas of hemorrhage, calcification, and necrosis
neuroblastoma
4 places a neuroblastoma can be found and what is most common?
abdominal mass (MC), often involving the adrenal gland
paraspinal mass
bone met
bone marrow
What would be the S/Sx of an abdominal neuroblastoma?
distention
pain
constipation
“blueberry muffin sign”
What is blueberry muffin sign?
bluish purple, palpable sucutaneous abdominal nodules
What would be the S/Sx of a paraspinal neuroblastoma?
Spinal cord compression with change in gait or sensation
Avoiding use of a limb
What would be the S/Sx of a bone met neuroblastoma?
bone pain
limp
if orbital involvement: proptosis, periorbital ecchymosis
What would be the S/Sx of neuroblastoma with bone marrow involvement?
low grade fever
malaise
myelosuppression
What does orbital/skull envolvement of neuroblastoma look like?
cephalomegaly and mass
sunken, raccoon eyes
Neuroblastoma might present with this syndrome
Horner Syndrome
Neuroblastoma might secrete catecholamines, causing …
HTN
Neuroblastoma might cause intractable diarrhea due to
tumor secretion of VIP (vasoactive intestinal peptide)
Neuroblastoma work up includes: (7 things)
- complete H&P
- CT or MRI of primary tumor
- Bone films and MIBG scan
- Bilateral bone marrow aspirate and Bx
- Urinary catecholamines (VMA, HVA)
- Labs: CBC, ferritin, neuron specific enolase
- Bx tumor tissue
What part of the lab workup for neuroblastoma is most diagnostic?
urinary catecholamines
What is MIBG scan used for ?
to image both primary and metastatic neuroblastoma
used SPECIFICALLY for neuroblastoma
How is MIBG scan performed?
Prep with thyroid blockade (K+ iodide) which prevents excessive radioiodine levels in the thyroid
Radiolable attached to Iodine-131, injected into vein, then scanned
MC sites of neuroblastoma mets
BONE MARROW
BONE (commonly orbits/skull)
LYMPH NODES
soft tissue
liver
lung
leptomeningeal involvement (late stage)
Staging neuroblastoma
based on age, risk, bodily involvement
classifications: high, intermediate, or low risk
Who has the prognosis with neuroblastoma?
children diagnosed at 12 months old or younger
How to treat neuroblastoma?
based on age, risk, stage
chemo surgery radiation to tumor bed autologous bone marrow transplant followed by 6 months of cis-retinoic acid MIBG therapy antibody therapy
Neuroblastoma is almost always diagnosed at stage:
3 or 4
An adverse indicator in neuroblastoma is:
N-myc amplification
MC intraocular malignancy of childhood
retinoblastoma
Retinoblastoma is MC in:
sex:
age:
race:
M=F
<4 years
no race predominance
A mutation in what gene is associated with retinoblasoma
RB gene
Where do retinoblastomas originate?
posterior retina
What can be described as a mass characterized by areas of necrosis, frequently calcified foci?
retinoblastoma
retinoblastoma can originate from one or more foci in one or both eyes, in rare cases it can be trilateral with a focus in the ___
pineal gland
S/Sx of retinoblastoma
- LEUKOCORIA: white reflex or “cat’s eye” reflex
- strabismus
- inflammation of conjunctiva or sclera
- orbital cellulitis
- proptosis
Retinoblastoma work up includes (4 things)
- Complete H&P
- Funduscopic exam under anesthesia!!
- CT scan and MRI of the orbits and brain
- Bone marrow aspirate and spinal tap for disseminated disease (rare)
3 patterns of retinoblastoma spread
- local intraocular extension into the vitreous
- Distant mets through the optic nerve or hematogenous dissemination
- trilateral retinoblastoma: pineal tumor
Tx of retinoblastoma
ENUCLEATION
- systemic chemo
- cryotherapy
- laser photocoagulation
- brachytherapy/plaque
- intra-arterial chemo via opthalmic artery (v complex and risk, not many docs trained to do this)
- Intra-vitreal chemo
- external beam radiotherapy
5-year prognosis of retinoblastoma
95% disease-free survival
What is associated with very poor outcomes of retinoblastoma?
CNS involvement
What predisposes child to a second malignancy, especially osteosarcoma?
Bilateral familial retinoblastoma
Neuroblastoma is to adrenal gland as Wilm’s tumor is to
kidney
MC primary malignant tumor
Wilms’ tumor
unilateral Wilm’s tumor is most commonly Dx at what age?
boys: 41.5 months
girls: 46.9 months
bilateral Wilm’s tumors are most commonly Dx at what age?
boys: 29.5 months
girls: 32.6 months
describe wilms’ tumor on imaging
well-defined borders due to the pseudocapsule, tumor coming out of the kidney
Wilms’ tumor is MC in
sex:
age:
race:
M:F .9:1.0
3-4 years
black > caucasian > asian
what type of tumor can be described as a rapidly growing soft kidney mass, cystic, vascular, friable, often with pseudocapsule
Wilm’s tumor
There is favorable histology in ____% of cases of wilm’s tumor
95%
what are the three types of favorable wilm’s tumor histology?
blastemal, stromal, epithelial
what is the unfavorable type of wilm’s tumor histology?
anaplastic
S/Sx of Wilm’s tumor
asymptomatic abdominal mass!!
Macroscopic or gross PAINLESS hematuria!!
HTN in 25% of cases abdominal pain malaise anorexia vomiting anemia rapid abdominal enlargement, significant anemia, and hypotension are seen in a subset of patients with sudden subcapsular hemorhage (worry about capsular rupture!) neuro signs if brain mets
primary wilm’s tumor may spread to the ___ or ___, which is associated with much worse prognosis
IVC (3%) right atrium (.8%)
Wilms’ tumor workup includes: (5 things)
- complete H&P, note size of mass, location, presence of GUi anomolies
- Labs: CBC, renal and liver function, chemistries, UA
- US and CT of the abdomen
- Chest CT (MC site of mets, everyone gets one no matter what)
- Tumor tissue (nephrectomy) rare, imaging is usually Dx
3 patterns of Wilm’s tumor spread and the most common
- lung mets are MC site of mets, followed by liver
- Extrarenal spread from direct extension through the renal capsule and/or lymphatic vessels
- Regional lymph nodes and the vena cava may be involved
Wilms’ tumor Tx
- Surgery for Tx and staging. MUST BE V CAREFUL NOT TO RUPTURE PSEUDOCAPSULE»_space; high rate of abd recurrence
- Chemo
- Radiation therapy
Radiation therapy for Wilms’ tumor according to stage
I-II: not typically necessary
III: abdominal
IV: abdominal + lung
IF ANY TUMOR SPILLAGE: whole abdominal radiation
Prognosis of Wilms’ tumor is related to: (5 things)
- stage of disease
- histology (favorable vs unfavorable)
- Patient age (younger is better)
- Tumor size
- Team approach to Tx: surgery, nephrology, oncology
Poor prognosticators for wilms’ tumor (5 things)
- mets at time of Dx
- lymph node involvement
- early recurrence (within one year of Dx)
- increased age
- anaplastic histology
What type of tumor is described as a malignant tumor of mesenchymal cell origin most often arising from skeletal muscle lineage?
rhabdomyosarcoma
Rhabdomyosarcoma is most common in
sex:
age:
race:
M:F 1.3:1
<9 years old
caucasian, african
2 associations with rhabdomyosarcoma
NF
Li-Fraumeni– a P53 mutation that predisposes pts to multiple cancers including rhabdomyosarcoma
pathophys of rhabdomyosarcoma: a ___, ___, ____ cell arising from ____ cells
small, round, blue
mesenchymal
rhabdomyosarcoma has characteristics of ____ cells
muscle (actin, myosin, desmin, myoglobin)
5 histological types of rhabdomyosarcoma and the MC
embryonal (MC) alveolar (MC) botryoidal spindle cell undifferentiated
Rhabdomyosarcoma:
The ____ type involves mucosa
The _____ type involves the extremities
embryonal;
alveolar
Orbital S/Sx of rhabdomyosarcoma
ptosis, lid swelling, proptosis
Paranasal sinus S/Sx of rhabdomyosarcoma
chronic sinusitis, epistaxis, swelling, pain
Nasal pharynx S/Sx of rhabdomyosarcoma
nasal speech, discharge, obstruction, mass
Middle ear S/Sx of rhabdomyosarcoma
chronic OM, mucopurulent or serosanguinous drainage, facial nerve palsy, mass in ear canal
Head lesions of rhabdomyosarcoma may lead to…
intracranial spread with S/Sx of increased ICP, meningeal S/Sx
rhabdomyosarcoma may present with mass in the…
trunk, extremity, paratesticular region
Prostate/bladder S/Sx of rhabdomyosarcoma
urinary tract obstruction, other urinary Sx
Vagina/uterus S/Sx of rhabdomyosarcoma
discharge, bleeding, polypoid mass
Rhabdomyosarcoma workup includes: (7 things)
- complete H&P
- CT or MRI and plain film of primary site
- bone scan
- CXR and CT scan (often spreads to lungs)
- Bilateral bone marrow aspirate and Bx (can easily spread to bone marrow, poor prognostic indicator)
- Tumor Bx
- Labs: CBC, chemistries, liver and kidney function
Rhabdomyosarcoma Tx
- chemo
- surgery (preferred to radiation)
- radiation
Combo chemo therapy for rhabdomyosarcoma
VAC:
Vincristine
Actinomycin D
Cyclophosphamide
____ and ____ rhabdomyosarcoma have the best prognosis
orbital, GU
nonbladder, nonprostate
____, _____, ____, ____, ____, and _____ rhabdomyosarcoma have the worst prognosis (~70%)
extremity cranial parameningial trunkal pelvic retroperitoneal paravertebral
Prognosis for rhabdomyosarcoma that involves the bone marrow
<20%
two positive prognostic indicators for rhabsomyosarcoma
early response to Tx
localized Dz
What is the most important negative prognostic indicator for rhabdomyosarcoma?
PAX-FOXO1 fusion!!!
What is the MC bone tumor of childhood?
osteosarcoma
Osteosarcoma is MC in
sex:
age:
race:
M:F 1.5:1
adolescent
all
peak age for osteosarcoma
12-16
3 predispositions to osteosarcoma
Li-Fraumeni syndrome
hereditary retinoblastoma
TALL!!
osteosarcoma arises from _____ and produces _____.
connective tissue
bone
what is a multifocal osteosarcoma?
involves more than one bone.
v rare but v poor prognosis
MC sites for osteosarcoma
tend to happen near a joint... distal femur proximal tibia proximal humerus distal tibia proximal femur
may occur in any bone
S/Sx of osteosarcoma
pain, swelling limited ROM increased warmth, vascularity pathological Fx pain worse at night
Tell pts with osteosarcoma not to _____ because _____
walk!
they could get a fracture at any time, then suffer pain and spread of the cancer
4 patterns of spread of osteosarcoma
- hematogenous to the lungs– by far the MC site of mets
- skip mets
- bone mets (rare)
- brain, lymph, kidney (rare, towards end of Dz)
What are skip mets?
a met to the same bone, with healthy bone in between
Workup for osteosarcoma includes: (10 things)
- complete H&P
- x-ray of primary tumor
- CT scan and MRI of primary tumor
- Nuclear bone scan/PET-CT
- CXR and chest CT looking for lung mets
- Labs: CBC, chemistries, kidney and liver function, coag studies, UA, urine Cr clearance
- Tumor markers: LDH, Alk Phos!!
- EKG, ECHO
- audiogram
Standard Tx for osteosarcoma
- neoadjuvant chemo
- local control (amputation, limb sparing surgery, radiation)
- adjuvant chemo
neoadjuvant vs adjuvant chemo for osteosarcoma
Neoadjuvant: MAP= Methotrexate, Adromycin (Doxorubicin), Cisplatin
Adjuvant: same as neoadjuvant
Limb salvage surgery for osteosarcoma
metal endoprosthesis, autograft, allograft, composite with bone + metal
4 types of surgery to Tx osteosarcoma
limb salvage
amputation
rotationplasty (must be in distal femur)
resection of primary tumor without need to reconstruct
what is an autograph?
replace a section of bone with a piece of another bone
Main Tx for osteosarcoma
surgery surgery surgery
2 things that are associated with improved outcomes of osteosarcoma
localized Dz
response to pre-op chemo
the second MC malignant bone tumor of childhood (can also be found in soft tissue)
Ewing’s sarcoma of bone
ewings sarcoma of bone is MC in
sex:
age:
race
M:F 1.3:1
second decade of life
rare in asian, african
Genetic predisposition to ewings sarcoma of bone
translocation t(11;22)!!!!!
Can’t make the Dx without a translocation here
ewings originates in the _____
neural crest
ewings sarcoma is a ____, ____, _____ cell
small round blue
What test detects cells with rearranged Ewings gene?
FISH: fluorescent in-situ hybridization
S/Sx of Ewings
pain
palpable mass
primary sites evenly distributed between extremities and central axis
pathologic Fx possible
extremity lesions tend to occur in diaphysis
if paravertebral: neurologic Sx (can even be CC)
unexplained fever
malaise
weight loss
increased skin temp
MC bony sites of Ewings
LEs, chest wall, pelvis
MC outside bone sites of Ewing
trunk, extremity, H/N
2 patterns of Ewings spread
- lungs MC site of mets
2. bone marrow may be involved at Dx
Ewings workup:
same as osteosarcoma except:
- bone marrow aspirate and Bx might be done
- audiogram and Cr clearance not required
Tx of Ewings
chemo, local control, more chemo
surgery when possible
radiation therapy might replace surgery or used in addition to surgery
chemo for Tx of Ewings
combo: Vincristine Adriamycin Cyclophosphamide Ifosfamide/Etoposide
prognosis of Ewings differs greatly between ____ and ____ disease
localized
metastatic
Cancer survivors can suffer from many effects from treatment with ___, ___, ___, and often have to be managed ____.
radiation
chemo
surgery
long term
Long term management of cancer survivors includes multiple tests: (10 things)
- Echo: if RT to chest (monitor for HF)
- PFTs: any Sx or with certain chemo drugs
- carotid doppler: 7-10 years s/p
- colon cancer screening earlier than normal: if received craniospinal RT
- CBC: look for secondary malignancy (leukemia)
- neuropsych testing: chemo brain
- infertility
- ototoxicity
- renal toxicity
- reduced bone density
