pediatrics Flashcards
why are common PMHx not present in pediatric patients?
pediatric patients will have different common PMHxs than adults as they have not had the time for damage accumulation that causes many chronic condition and comorbidities to develop
what factors comprise pediatric SHx?
living circumstances, daycare/school, care-taker, secondhand smoke exposure, tobacco, alcohol, or drug use, immunization status
what kind specific questions would the provider ask to help understand a pt’s SHx?
- who is the patient’s caregiver? (mom, dad, foster, parents, etc)
- any known ill contacts? (do they attend daycare or school? do they have any siblings?)
- other questions for teenagers? (tobacco use, ETOH, drug use, sexually active)
what are the age/grade groupings?
neonate: <4 w/o; infant: 1-12 mo; toddler: 1-4 y/o; pre-schooler: 3-5 y/o; kindergartener: age 5; 1st grade: age 6; 2nd grade: age 7; 3rd grade: age 8; middle schooler: 11-13 y/o; high schooler: 14-18 y/o
what part of the patient history is immunization status?
social history
why do children need so many vaccines?
infants are born with very little immunity and are particularly susceptible to severe infections. vaccines offer some additional protection by teaching the immune system early on to recognize and respond to some specific types of infections that children are very prone to catching
why do children need so many vaccines?
infants are born with very little immunity and are particularly susceptible to severe infections. vaccines offer some additional protection by teaching the immune system early on to recognize and respond to some specific types of infections that children are very prone to catching
toxic
toxic-appearing, infants and children are pale or cyanotic, lethargic, or inconsolably irritable, may have tachypnea and tachycardia w poor capillary refill
lethargic
poor or absent eye contact; failure of child to recognize parents or to interact w persons or objects in the environment - ONLY DOCUMENT AFTER CONFIRMING TO DO SO
febrile
state of having a fever
inconsolable
pts w constant high levels of irritability that are not able to be comforted
turgor
elasticity of the skin; poor skin turgor is an indication of dehydration
describe dehydration
a shortage of fluids commonly caused by vomiting or diarrhea
what is the CC of a pt with dehydration
lethargic/listless, sunken eyes, poor urine output (PUO)
describe kawasaki disease
inflammation of and extensive damage to the blood vessels, unknown cause
what is the chief complaint of a person with kawasaki disease
constant fevers (for many days)
what are the associated symptoms of kawasaki disease
cervical lymphadenopathy, red, dry, cracked lips, swollen tongue, erthyematous palms and soles, rash to the mid-section of the body and genitals
how is dehydration diagnosed
clinically, or based on the Na+ levels from a BMP
what PE findings would be observed in a pt with dehydration
dry mucous membranes, crying w/out tears, poor skin turgor/tenting
why is it important to always document fevers as intermittent?
kawasaki disease, which consists of constant fevers. guardians will carelessly say their children has had a fever “constantly for 4 days” when the fever has actually improved after motrin. DO NOT document a constant fever for more than 24 hours unless told to do so by your physician
the physician performs a PE on a pt and finds that the pt is febrile, tachycardic, has “strawberry tongue”, and has a red rash on the palms of hands and soles of feet. what is a potential ddx?
kawasaki disease
how is kawasaki disease diagnosed
clinically
what is hand, foot, and mouth disease
viral infection (coxsackie) that can cause sores to the palms, soles, and w/in mouth, commonly seen in children who attend daycare/school
what is the CC for HFM disease
blisters on the hands, feet, and mouth
what is a major concern of HFM disease?
dehydration given the pain experienced with PO intake. be aware of signs of dehydration such as decreased UOP, dry mucous membranes, crying without tears
what are the associated sx of HFM disease
lowered PO intake
describe tachycardia
fast HR caused by a large variety of conditions, most commonly fever. the definition of tachycardia varies between pediatric age groups
diagnosed by: bedside telemetry or if tachycardia noted during exam
what is considered tachycardia for a newborn?
> 160 bpm
what could a physician potentially find during a PE on a pt with HFM disease?
lesions on the tongue, posterior pharynx, buccal mucosa, and gingiva
what is considered tachycardic for a less than 6 month old?
> 180 bpm
what is tachycardic for a 1-2 y/o?
> 160 bpm
what is tachycardic for children ages 3-10 y/o?
> 140 bpm
what is tachycardic for children 11-15?
> 120 bpm
what is considered tachycardic for adults?
> 100 bpm
describe myocarditis
infection of the myocardium, usually viral, that causes CP in older children
what is the chief complaint for myocarditis
chest pain
what are the most common causes of chest pain in children?
very rare for CP in children to be cardiac-related. common causes are musculoskeletal pain, costochondritis, pleurisy (inflammation of pleura), reflux, asthma, pneumonia
what are the associated sx of myocarditis
lethargic/listless, irritable, low grade fever
what are some PE findings of myocarditis
tachycardia, decreased capillary refill, gallop
describe asthma
constricting of the airways due to inflammation and muscular contractions of the bronchioles
CC: SOB/wheezing, improved w bronchodilators
assoc. sx: hoarseness of voice, labored breath, fever
PE: wheezes
diagnosed by: clinically
what are some associated sx of asthma
hoarseness of voice, labored breath, fever
what are some associated medications used for asthma?
-short-acting beta agonist (SABA): used acutely via inhalers and nebulizers [albuterol or atrovent]
- long acting beta agonist (LABA): always w/ corticosteroid combination, used as daily controller medication via inhaler [symbicort]
-glucocorticoid: prednisone, prednisolone, decadron
describe pertussis (whooping cough)
infection of the respiratory tract causes a dry harsh cough that can last up to 100 days (“100 days cough”)
CC: cough
assoc. sx: post-tussive emesis
PE: often unremarkable, may exhibit cough during exam
diagnosed: clinically, likely w/ negative CXR and maybe sputum culture
what is the chief complaint of pertussis
cough
what is post-tussive emesis
harmless type of vomiting that occurs after long coughing spells, not GI related. be sure to differentiate it from normal vomiting
what medication can be used to treat pertussis
abx such as azithromycin
what is the assoc. sx of whooping cough
post-tussive emesis
describe bronchiolitis (RSV)
infection of the lower branches of the lungs leads to difficulty breathing
what is the chief complaint of RSV (bronchiolitis)
SOB, grunting
what are some assoc. sx of RSV
fever, cough, wheezing, poor feeding, irritability
what is especially important to document for respiratory pt and bronchiolitis
oxygen saturation
what are the signs of respiratory distress
retractions, tachypnea, accessory muscle use, belly breathing, nasal flaring
what are some PE findings consistent with RSV
inspiratory rales and expiratory wheezes, signs of respiratory distress
how is RSV diagnosed
CXR or RSV panel
describe croup
viral infection caused by the parainfluenza virus, causing swelling of the upper airway leading to a “bark-like” cough
what is the CC for croup
barking cough
what is the main concern with croup?
respiratory distress, should be treated with corticosteriods if showing signs
what is the main difference between asthma and croup?
same assoc. sx (fever, hoarseness, labored breath). asthma–> cc = sob/wheezing
croup–> cc = bark cough
what would a physician find in the PE of a pt who has croup
stridor, bark cough, retractions, signs of respiratory distress
what is stridor
noisy breathing that occurs due to obstructed air flow through a narrowed airway
how is croup diagnosed
clinically, likely with a negative CXR and potentially sputum culture
describe influenza
common viral upper respiratory infection that can deadly, especially in high risk groups
CC = dry, persistent cough, fever (>100.4F)
assoc. sx: fatigue, myalgia (muscle aches), headaches, nasal congestion, sore throat
assoc. med: tamiflu
PE: fever, nasal drainage
diagnosed by: rapid flu test
what is the CC of influenza
dry, persistent cough, fever
what are the assoc. sx of influenza
fatigue, myalgia, headaches, nasal congestion, sore throat
what age group is at high risk of developing flu complications
<5yr, especially <2yr
describe febrile seizure
seizure that results from rapid change in body temperature from fever (height of fever itself is not the cause)
CC: seizure like activity
assoc. sx: fever
PE: absence of postictal state
diagnosed: clinically
describe pyloric stenosis
enlargement of tissue surrounding the pyloric valve causes obstruction of the stomach
risk factors: >3months old
CC: vomiting (projectile)
assoc. sx: poor appetite, poor feeding, poor weight gain, poor satisfaction after meals
PE: firm, non-tender, mobile mass in RUQ, “olive-like”
diagnosed: clinically or by US of RUQ
describe intussusception
a section of bowel telescopes into an adjacent section, putting the pt at risk for blockage and gut-ischemia
risk fx: >2y/o
CC: sudden onset, episodic abd pain OR vomiting w/out diarrhea
assoc. sx: mucous or currant-jelly-like tools, pt appears completely well between episodes, potentially lethargy
PE: abd tenderness, abd distention, Guaiac positive stools
diagnosed by: contrast edema (not in ED) or AAS
describe constipation
difficulty having bowel movements (many causes) and subsequent buildup of stool w/in the lower GI tract
risk factors: dehydration, weak GI mobility, infants, chronic constipation issues
CC: absence of/difficulty w BM, no BM in 2-3 days
assoc. sx: pain w BM, abd pain, loss of appetite, encopresis (fecal incontinence)
pert. neg: no blood in stool, emesis, or loss of ability to pass gas
PE: rectal exam may be performed to assess stool burden in rectal vault, may be tenderness or distention, as well as an appreciable stool burden on abd exam
diagnosed by: AAS or situationally CT a/p w IV contrast (if concern for potential SBO)
what procedure can be done to relieve pt if determined they cannot pass the stool burden?
bowel disimpaction procedure, be sure to document
describe a toddler’s fracture
tripping/twisting of leg causing a spiral fracture of the tibia, pain and limitation of use
CC: non-weight bearing on affected extremity
assoc. sx: will no put foot down, significant TTP, may still crawl
pert. neg: no focal weakness, no sensory deficits, no other injuries
PE: will not bear weight, point tenderness over distal tibia, CSMT intact distally
diagnosed by: XR of extremity
what is important to note in most extremity injuries
splint application procedure, if one was done
describe nursemaid’s elbow
(radial head subluxation[partial dislocation]) pulling motion on child’s wrist/forearm causes a subluxation of the radial head, causing pain and limitation of use
CC: child not using affected arm
assoc. sx: child holding their arm at their side, crying that is made worse w attempted use of arm
pert. neg: no motor weakness, no bruising/swelling
PE: child holding arm at side, no focal point tenderness, CSM intact distally
diagnosed: clinically
what procedure will physicians typically do to treat nursemaid’s elbow
physician’s will often reduce joint by hyperpronation and/or supination w/ flexion
describe the presentation of foreign bodies
foreign objects can become lodged in the body such as ear canal, nose, eye or throat
CC: ingestion/choking or “something stuck in nose/ear”
PE: describe the foreign body; size, shape, location
diagnosed by: direct visualization of the foreign body on exam or XR
what should you always document in regards to foreign bodies?
document respiratory status (no SOB, airway patent, breathing easily, etc) as well as FB removal procedure for anything that is removed by the physician
describe otitis media
middle ear infection, viral or bacterial infection of TM causing ear pain and pressure
CC: ear pain, ear pulling
Assoc. sx: fever, sore throat, dry cough, congestion
PE: erythema, effusion, bulging, or dullness of the TM
diagnosed: clinically
what would a pt with a bite c/o
a break in the skin caused by the teeth of either an animal or another person; bite/wound, be sure to document the pt’s vaccination status including rabies and tetanus
what is tinea corporis and capitis
ringworm; a fungal infection of the skin (corporis) or hair follicles of scalp (capitis); CC: erythematous and circular rash, alopecia also coming as the fungus permeated the follicle
what is scabies
a mite that burrows and lives just below the surface of the skin
CC: itchy rash, commonly to hands, feet, waistline, or specifically for babies on the back
describe atopic dermatitis (eczema)
several types, all share the feature of irritated skin that generally involves inflammation, erythema, itching, and flaking
CC: rash, FHx of eczema, history of eczema flares
what is candidiasis
yeast infection of the skin that forms in dark, damp areas such as the inguinal folds or between fat rolls on the babies neck
CC: rash w skin breakdown at rash site
what is important to include in the pediatric HPI
must include who the pt presented w/, generally parents
what are the HPI buzz-words
lethargic, inconsolable, listless. these should not be used in the HPI unless instructed by the provider
what should you use instead of lethargic
generally tired
what should you use instead of inconsolable
crying slightly more often
what should you use instead of listless
playing less often
t/f: you should always pair positive findings with other related negatives
true
“mildy generally tired…but still active”
“crying slightly more often…but has been consolable”
“playing less often…but still eating and drinking well”
what are the 3 major concerns to pay attention to for the peds ED? how would you document this?
changes in appetite, changes in activity, changes in alertness. if one of these three areas is changed, be sure to document the areas that are not affected
what are some common febrile illnesses
febrile seizures, strep pharyngitis, OM, viral illness, UTI
what are some serious febrile illnesses
meningitis, kawasaki disease, appendicitis, pneumonia
what are the 5 important details to document for pt w/ fevers
- onset - any constant fever lasting >1-2 days is a concern
- timing - all fevers are documented as intermittent until proven constant
- T-max - max temp
- measurement - any fever w/out an actual temp document must be documented as “subjective fever” meaning no temp has been taken
- medications: any antipyretic, medication, or herbal remedy given and when they received their last dose
when and where should birth history be recorded
for any pt > 12 month old, recorded at the end of HPI
what type of questions would be included in the BHx
how many weeks pregnancy carried? vaginal delivery or C-section (and why)? did pt stay in NICU (why)? circumcised? was the mother treated w Group B Strep at delivery? did mom have an STD or UTI which was treated? did pt leave w the mother after birth?
what is the single most important section of the PE for peds?
the general/constitutional section
what are some normal and abnormal findings of the constitutional section of PE
-normal: NAD, alert, attentive, interactive, completely non-toxic, smiling, playful, well-hydrated, well perfused, cries normally w/ tears during exam, but is easily consolable, vigorous
-abnormal: fussy/irritable but consolable, mildly ill appearing but non-toxic
what is the chief complaint for myocarditis
chest pain
