Pediatrics

Question 1

stridor

Answer 1

upper airway obstruction

Question 2

wheezing

Answer 2

lower airway obstruction

Question 3

most common virus in common cold of children?

Answer 3

RSV, seem november to march, causes bronchiolitis

Question 4

what causes croup?

Answer 4

parainfluenza virus

Question 5

when do you give Abs to kids with sinusitis?

Answer 5

1. persistence of nasal discharge for more than 10 days w/out improvement
2. severe sx: high fever for 72 hours, not eating
3. worsening sx or pus filled discharge

Question 6

herpangina

Answer 6

Discrete erythematous-based macules –> evolve into papules that vesiculate and then ulcerate centrally, creating an erythematous halo. (seen in posterior)

caused by Coxsackieviruses A 1-10, 12, 16, and 22

Question 7

strep pharyngitis

Answer 7

sore throat, fever, h/a, GI sx, NO COUGH OR RHINORRHEA!!!

sometimes have abdominal sx along with this

exudative pharyngitis, anterior cervical lymph nodes, palatal petechiae, scarlatiniform rash (linear rash)

* rapid strep with back up culture if negative*

Can’t tell by just looking

tx: Penicillin V or Amoxicillin (tastes good!)

only seen in over 3 y/o…

Question 8

peritonsillar abscess?

Answer 8

• most common deep neck infection in children and adolescents
• due to a collection of pus located between the capsule of the palatine tonsil and the pharyngeal muscles

** gold std for ddx: collection of pus from abscess through needle aspiration **

Symptoms include:
severe sore throat (usually unilateral)
Fever
"hot potato" or muffled voice
Pooling of saliva or drooling may be present
Trismus
neck swelling and pain
ipsilateral ear pain
Fatigue
Irritability
decreased oral intake 

** usually polymicrobial **

Question 9

Epiglottitis

Answer 9

4 D’s: 
Drooling
Dysphagia
Dysphonia
Dyspnea

Toxic appearing

“Tripod” position, “sniffing” position

Management if suspected:
*Direct examination of the airway under anesthesia (with the availability of personnel who can perform a tracheostomy if needed)

** call anesthesia right away, this kid is really sick

Question 10

Croup

Answer 10

laryngotracheitis = parainfluenza virus

Typical features of croup include :
nasal congestion
low-grade fever
**barking-type cough
**inspiratory stridor that may worsen with crying. 

see “steeple sign”

or called LTB = laryngotracheobronchitis

Question 11

tx of croup?

Answer 11

inhaled racemic epinephrine

Question 12

bronchiolitis?

Answer 12

more than half due to RSV (in infants younger than 6 mos)

ddx: increased respiraotry effort, tachypnea, nasal flaring, chest retraction, wheezing, rales (a mix of pneumonia and asthma)

= upper respiratory sx followed by lower respiratory infection –> wheezing and or crackles

Question 13

when do you admit kids with bronchiolitis?

Answer 13

admit if child is hypoxic or dehydrated

Question 14

obscured costovertebral angles ?

Answer 14

indicative of pleural effusions, must be drained

Question 15

adolescent pneumonia with milder sx? wheezing, dysnpea, mildly productive cough, scattered rales and wheezes, low grade fever?

Answer 15

mycoplasma pneumonia, most common atypical pneumonia seen in adolescents or children over 5 y/o

• Gradual onset and usually is heralded by headache, malaise, and low-grade fever
• Occasionally can be more acute and mimic pneumococcal pneumonia
• Nonproductive to mildly productive cough
• Wheezing and dyspnea also may occur
• Scattered rales and wheezes on lung exam may be present

Question 16

viral pneumonia vs bacterial CXR?

Answer 16

bacterial is usually lobar, diffuse infiltrates usually indicates viral

Question 17

impairment vs. risk of asthma

Answer 17

impairment = categories of exercise induced, intermittent, mild, moderate and severe persistence

risk = more related to severity of episodes in conjunction with frequency of events

asthma is having trouble breathing out, vs. vocal cord dysfunction is having trouble breathing air in

Question 18

most important medication used on children with asthma?

Answer 18

inhaled corticosteroids - tx the chronic inflammation, and decreased inflammatory mediators –> results in mm. being much less likely to be hyperresponsive

Question 19

15 y/o female, known asthmatic, presents with cold for week, fever, cough, SOB, vomiting - on flovent (inhaled steroid), using albuterol 2x every 4 hours.

Answer 19

• acute exacerbation of chronic underlying disorder - use bronchodilator for rapid response (nebulizer tx of albuterol multiple times) for the in office tx and give her O2 in the office; also give oral steroids that will kick in in 4-6 hours.
• ultimately need to change her asthma tx so that it is under control: add LABA or Leukotriene* along with inhaled steroids (medium dose, don’t want to do high dose in a younger patient) along with continued use of albuterol

other differentials for her: acute exacerbation of asthma, vocal cord dysfunction, anxiety attack

Question 20

2.5 year old male, sudden onset of wheezing. no fever, coughing, vomited one time, tachypnic, using accessory respiratory mm, nasal flaring, drooling some, diffuse wheezing, decreased air exchange, pale

Answer 20

ddx: aspiration (worried about this due to his age and its sudden onset), anaphylaxis, asthma**
tx: give albuterol nebulizer and give O2 - short term

longer term tx: put on inhaled corticosteroids and have him come back in every few months

Question 21

7 y/o presents with well check up, SOB when playing soccer, wakes up at night, pleasant boy in no acute distress

Answer 21

ddx: exercise induced asthma, or mild persistent asthma

Use SABA albuterol PRN, maybe use corticosteroid if needed

Question 22

3 month mom notices not feeding well, cough, a little temp, fussy, see right TM that is dull with fluid level and red, lungs show scattered wheeze, rhonci and rales in bases, see tachycardia

Answer 22

bronchiolitis

Question 23

30 week gestational age, C-section, primigravida fetal distress.

Answer 23

Worry about RDS
Immediate actions: surfactant administered through ET tube

decreased surfactant –> atelectasis –> uneven perfusion, hypoventilation –> acidosis –> makes it worse –> pulmonary vasoconstriction/HTN –> endothelial damage –> hyaline membrane disease and fibrin formation

Mom is found to be + for CMV

Question 24

CMV infections in newborn?

Answer 24

DNA virus of herpes virus group

CMV infection results in characteristic massive enlargement of the affected cells that contain intranuclear and cytoplasmic inclusions

see “owl eye”

CMV infection is the most common congenital viral infection

infants have mental retardation, cerebral palsy of most commonly, hearing impairment

transmitted through person to person - can go dormant and then be reactivated during pregnancy

Question 25

transmission of CMV?

Answer 25

prenatal: occurs after primary infection of mother - can occur anytime during pregnancy: only 10-15% of infected victims manifest sx at birth

Natal infection: can occur during birth if mom is seropositive - 50% of these become infected with disease that is manifested at 4-6 weeks of age

Postnatal: most often spread in breast milk and 50-60% of infants will become infected

Question 26

clinical manifestations of CMV?

Answer 26

• Intrauterine growth restriction
• Hepatosplenomegaly
• Jaundice
• Petechiae or purpura
• “blueberry muffin” spots
• Microcephaly
• Chorioretinitis
• ***Sensorineural hearing loss-Occurs in 30% to 65% of symptomatic infants and 5% to 15% in asymptomatic infants
• Cerebral calcifications

Other findings: poor feeding, pneumonia, lethargy, hypotonia, seizures

Lab tests: coombs (-) hemolytic anemia, elevated liver enzymes, elevated CSF protein

Question 27

bronchopulmonary dysplasia

Answer 27

= babies with emphysema due to O2 treatment

• a chronic lung disease occurring in premature infants with RDS that were treated with mechanical ventilation and supplemental oxygen that developed chest X-rays that showed “coarse, streaky infiltration with small areas of emphysema and occasionally appeared cystic”
• BPD is rare infants with a gestational age > 30 weeks and weights of > 1200 grams
• It is seen in 30% of babies under <1000 grams and less than 32 weeks gestation

Question 28

radiographic stages of BPD

Answer 28

Stage I-(2-3) days after birth Chest X-ray shows typical granular appearance of RDS

Stage II-(4-10) days after birth X-ray shows complete opacifcation of the lung

Stage III-(10-20) days after birth X-ray shows round cystic lucencies with alternating opacities

Stage IV-after 1 month X-ray shows enlargement of the lucencies with increasing strands of opacity (Bubbly Lung)

Question 29

chronic cough in pediatric patient?

Answer 29

more than 3 to 4 weeks

Question 30

cough after feeding in newborn

Answer 30

may be overfeeding, GERD or TEF

if cough stops when cut down volume of feedings - then most likely due to overfeeding

if cough worsens with feeding associated with vomiting then think GERD

if cough worsens with feeding, no vomiting then tracheo-esophageal fistula should be considered

Both GERD and TEF can be associated with wheezing, cyanosis and tachypnea

Question 31

cough associated with tachypnea?

Answer 31

think about sepsis

Question 32

cough associated with cyanosis that is relieved with O2?

Answer 32

think intrapulmonary process

Question 33

if cough with cyanosis thats not relieved by O2?

Answer 33

suggest CHD with R to L shunt - this finding with or without murmur reqs. a thorough cardiac evaluation

Question 34

cough in infancy?

Answer 34

RSV infection-infants at higher risk include preterm infants, cyanotic heart disease or immunodeficiency

A staccato cough in the first few months of life suggests infection with Chlamydia trachomatis pneumonia

Pertussis may cause spells of whooping with apnea

Question 35

cough in a toddler?

Answer 35

Asthma must be considered in this age group but because toddlers cannot perform spirometry it can be a difficult diagnosis

Bronchiectasis may be present if the toddler has CF, ciliary dyskinesia or immunodeficiency

The cough of bronchiectasis is described as wet

Chronic middle-ear disease, allergy and sinusitis can cause chronic cough (these have reflexes for cough)

Question 36

cough in adolescent

Answer 36

Asthma is a common cause of chronic cough

Tumors in the chest (rare) can cause chronic cough in this age group - think mediastinal mass

Vocal cord dysfunction that is often associated with stress or exercise can mimic exercise induced asthma with sudden symptoms of inability to breathe

Question 37

if suspect epiglottitis?

Answer 37

from H. influenza, DO NOT STICK anything down his throat to examine it - if its epiglottitis the child needs to be intubated