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Pediatrics 3 Flashcards

1
Q

Peak age of Infectious mononucleosis

A

15-19 yr

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2
Q

EBV transmission

A

Infected saliva

Sexual

Incubation: 1-2 mo

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3
Q

Sx of Infectious mononucleosis

A

Infants/young children:
Often asymptomatic or mild

Older children and adolescents:
Malaise, fatigue, fever, sore throat, abd pain (LUQ)
Periorbital edema
Any -itis

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4
Q

Triad of IM

A

Fever

Generalized LAP

Pharyngitis/tonsillitis (exudative)

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5
Q

IM Dx

A

Monospot test:
Sensitivity increases with age
Tests heterophil ab
False positive in: HIV, SLE, Lymphoma, rubella, parvovirus

EBV titres

CBC, diff, blood smear

Throat culture to R/O streptococcal pharyngitis

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6
Q

Mx of IM

A 
Supportive:
Adequate rest
Hydration
Saline gargles
Analgesics

All pts should avoid contact sports for 6-8 wk

If airway obstruction:
Admit
CS

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7
Q

Neurologic complication of IM

A

Guillain-Barré

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8
Q

Etiology of infectious pharyngitis

A

80% viral

20% bacterial:
Mainly GAS
M. Pneumoniae
N. Gonorrhea

Fungal: candida

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9
Q

GAS pharyngitis is uncommon in age:

A

<3 yr
Peak: 5-12 yr

Late winter, early spring

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10
Q

If suspected GAS pharyngitis, next step?

A

Rapid streptococcal Ag test

If negative:
Throat culture

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11
Q

Mx of streptococcal pharyngitis

A 
Penicillin V 
Or
Amoxicillin
Or
Erythromycin

Given within 9 d of Sx

x 10 d

Hydration
Acetaminophen

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12
Q

Indication of tonsillectomy for GAS pharyngitis

A

If proven recurrent strep pharyngitis

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13
Q

Role of antibiotic therapy and prevention of PSGN or rheumatic fever

A

Prevents rheumatic fever but not PSGN

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14
Q

PANDAS is a complication of

A

Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci

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15
Q

When and where does the rash of scarlet fever start

A

24-48 h after pharyngitis

Starts in folds

Within 24 h, sandpaper rash begins to generalize

No pain, No pruritus

Blanchable

Fades after 3-4 d

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16
Q

Tx if scarlet fever

A

Penicillin
Amoxicillin
Erythromycin

x10 d

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17
Q

Peak incidence of rheumatic fever

A

5-15 y

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18
Q

Criteria for diagnosis of rheumatic fever

A

Jones Criteria

2 major
Or
1 major + 2 minor + evidence of preceding strep infection

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19
Q

Tx of RF

A

Acute course:
Penicillin/erythromycin x 10 d
+ prednisone if severe carditis

Secondary prophylaxis:
Daily penicillin or erythromycin

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20
Q

PSGN peak age

A

4-8 yr

M> F

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21
Q

How long after strep pharyngitis does PSGN develop?

A

1-3 wk

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22
Q

Dx of PSGN

A

U/A
ASOT/anti-DNAseB
Low C3

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23
Q

Mx of PSGN

A

If symptomatic:

If HTN/edema:
Loop diuretics, Fluid/Na restriction

+/- dialysis

If evidence of persistent infection:
Penicillin, erythromycin

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24
Q

Peak age of meningitis in children

A

6-12 mo

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25
Meningitis risk factors
Unvaccinated Immunocompromised Recent or current infections Neuroanatomical defects/surgery/cochlear implant/dermal sinus, recent trauma Daycare Household contact Recent travel
26
Inv for meningitis
``` CBC, diff Lytes BUN, Cr Glucose, Blood C&S LP(gram stain, C&S, WBC, diff, RBC, glucose, protein, acid fast if suspect TB, PCR esp if treated with AB) ``` Urinalysis, S/C Gram stain/culture of petechial/purpuric lesions HSV/enterovirus PCR
27
CSF WBC count in normal newborn/infant
Infant: 0-6 (no PMN) Newborn 0-30 (2-3 PMNs)
28
CSF WBC count in meningitis
Bacterial: >1000, >50% PMN Viral: 100-500, <40% PMN HSV: 10-1000, <50% PMN
29
CSF Glucose in meningitis
Bacterial: < 1.66 Viral/HSV > 1.66
30
CSF protein in meningitis
Bacterial: > 1 Viral: 0.5-1 HSV: > 0.75
31
CSF RBC in meningitis
Bacterial: 0-10 Viral: 0-2 HSV: 10-50
32
Mx of meningitis
``` Supportive: Normal BP Mx ICP rise Fluid Lytes Acid-base Glucose Coagulopathies ``` Start AB if suspect bacterial meningitis Isolation Mx SAIDH (fluid restriction) Hearing test Reportable Prophylactic AB for close contacts (HI, N. Meningitis)
33
How long should isolation continue for meningitis
Until 24 h after culture-sensitive AB therapy
34
Opistotonos seen in
Meningitus Teranus
35
Empiric AB for meningitis in newborn
Ampicillin + cefotaxime
36
Empiric AB for meningitis in 1-3 mo infants
Vanco + cefotaxime + ampicillin if immunocompromised
37
Empiric AB for meningitis in infant > 3 mo
Ceftriaxone + vanco If penicillin allergy: Vanco + rifampin
38
Mx of viral meningitis
Supportive Acyclovir for HSV Report to public health
39
Meningitis with which organism causes higher mortality rates
Pneumococcus > N. Meningitis > HiB
40
Age of mumps
5-10 yr
41
Mumps transmission
Respiratory droplets | Direct contact fomites
42
Mumps communicability
7 d before to 5 d after parotitis
43
Dx of mumps
Clinical ``` But also: IgM PCR (oral secretions, blood, CSF) Viral culture CBC Amylase ```
44
Mx of mumps
``` Analgesics Antipyretics Warm/cold pack to parotid Admit if meningitis/pancreatitis... Droplet precaution ``` Px: vaccine
45
Transmission of pertuss
Respiratory deoplermts
46
Communicability of pertussis
Mostly during catarrhal phase But may remain contagious for weeks
47
Post-tussive apnea
In infents < 6 mo in paroxysmal phase of pertussis
48
Age of greatest incidence of pertussis
<1 yr
49
Duration of pertussis phases
Catarrhal: 1-7 d Paroxysmal: 4-6 wk Convalescenct: 1-2 wk (non-contagious) Cough may last up to 6 mo
50
Inv for pertussis
Gold: culture of NP specimen PCR to detect Ag CBC (lymphocytosis) Serology
51
Mx of pertussis
Admit if: apnea, cyanosis : O2 Supportive care AB if: B. Pertussis isolated, Or Sx < 21 d AB: macrolide Droplet isolation Reportable
52
Duration of droplet isolation for pertussis
Until 5 d of treatment
53
Indications for CT for sinusitis
Surgery Complications Persistent/recurrent disease
54
Indication of AB therapy for sinusitis
All children
55
UTI in boys and girls
< 4-6 wk old, more prevalent in boys > 1yr, more prevalent in girls
56
RFs fir URI
``` Female Caucasian Previous UTI FHx VUR Neurogenic bladder Obstructive uropathy Posterior urethral valve Dysfunctional voiding Repeated bladder cath Uncircumcised males Labial adhesion Sexually active Constipation Toilet training ```
57
Inv for UTI
Sterile urine specimen U/A, microscopy, C/S Dx if: suggestive U/A + > 50,000 CFU/ml in U/C
58
Bagged urine value for UTI Dx
Not useful for Ruling in, but iseful for ruling out UTI
59
Mx of UTI
Admit if indicated Supportive care: Hydration Pain control AB: Neonates: IV ampicillin and gentamycin Infants and older children: If outpt: oral AB If inpt: IV ampicillin + genta x7-10 d Imaging
60
Indications for admission of child with UTI
``` <2 mo Urosepsis Persistent vomiting Inability to tolerate oral medications Moderate to severe dehydration Immunocompromised Complex urologic pathology Inadequate follow-up Failure to respond to outpatient therapy ```
61
Indications for imaging in UTI
U/S for all febrile infants (<2yr) with UTI ``` VCUG: Not recommended after 1st episode of febrile UTI Unless: Signs suggestive of high-grade VUR: Hydronephrosis on U/S Obstructive uropathy on U/S ```
62
Definition of SGA
2 SD < mean wt for GA Or < 10th percentile
63
Definition of LGA
2SD > mean wt for GA Or > 90th percentile
64
Ca, BS, Hb in premature infant?
Hypocalcemia Hypoglycemia Anemia
65
Ca, BS, Hb in SGA
Hypocalcemia Hypoglycemia Polycythemia
66
Ca, BS, Hb in LGA
Hypocalcemia Hypoglycemia Polycythemia
67
Routine neonatal care
Ophthalmic erythro oint Vit K IM ``` Screening tests: Metabolic disorders Blood disorders Endocrine disorders Other genetic diseases Congenital hearing loss ``` If mother Rh - : send cord blood for BG and direct anti-globulin test
68
Screening tests for neonates:
``` Amino acid disorders Organic acid disorders Fatty acid oxidation defects Biotinidase deficiency Galactosemia SCD Hb-pathies CAH Hypothyroidism CF SCID Hearing loss ```
69
Neonatal care for neonate with HBsAg + mother
HBIg | + Hep B vaccine series
70
Neonate with APGAR < 7 at 5 min, next step?
Assess APGAR q 5 min until above 7
71
Steps to take immediately after birth
Warm and dry Put in sniffing position and clear airway Stimulate: rub lower back, flick soles Assess breathing and heart rate NO STIMULATION IF MECONIUM PRESENT ( tracheal suction first)
72
If neonate HR < 60 in delivery room
Epinephrine IV, ET
73
If evidence of hypovolemia in neonate
Fluid bolus NS, RL, Blood
74
Definition of depressed newborne
I depressed newborn lacks one or more of that following characteristics: Pulse > 100 Cries when stimulated Actively moves all extremities Good strong cry
75
Inv for depressed newborn
Detailed Hx CBC, ABG, blood type, glucose Transillumination of chest CXR
76
Periodic breathing in newborn. Definition, significance
Periods of rapid respiration alternating with pauses lasting 5 to 10 seconds Normal
77
Definition of apnea in neonate:
absence of air flow for > 20 s Or Less if bradycardia or desaturation
78
Apnea of prematurity
< 34 wk Resolves by 36 wk CNS immaturity and obstructive apnea Dx of exclusion
79
Mx of newborn apnea
Full workup O2, ventilation support, maintain normal blood gases Tactile stimulation Correct underlying cause Methyxanthines (caffeine): for apnea of prematurity (stimulates CNS/diaphragm)
80
Pathophysiology of neonatal alloimmune thrombocytopenia
Mother is negative for HPA, fetus is positive
81
Sx of neonatal alloimmune thrombocytopenia
Petechia, purpura, intracranial bleeding
82
Dx of neonatal alloimmune thrombocytopenia
Maternal and paternal platelet typing Identification of platelet alloantibodies
83
Tx of neonatal alloimmune thrombocytopenia
IVIg to mother starts in 2nd trimester +/- steroids +/- fetal plt transfusion IVIg to neonate Transfusion with washed maternal plt or donor HPA negative plt if required
84
Neonatal AI thrombocytopenia
Caused by: antiplatelet Ab from maternal ITP or SLE Sx less severe than neonatal alloimmune thrombocytopenia
85
Tx of Neonatal AI thrombocytopenia
Steroid to mother for 10-14 d prior to delivery Or IVIg to mother before delivery IVIg to neonate if plt < 60,000 Transfusion of infant with maternal/donor plt only in severe cases
86
Hemorrhagic diseases of the newborn
Vitamin k deficiency Both PT and PTT increase
87
RFs for vitamin k deficiency in neonate
Poor placenta transfer Insufficient bacterial colonization of colon Breastfeeding Mother taking AED
88
definition of bronchopulmonary dysplasia (chronic lung disease)
O2 requirement for > 28 d Plus Persistent need for oxygen/ventilatory support at 36 wk corrected GA
89
Etilogy of BOD
Prolonged intubation/ventilation/O2 | Infection
90
CXR in BPD
Decreased lung volumes Areas of atelectasis Signs of inflammation Signs of hyperinflation
91
Tx for BPD
Gradual wean from ventilator Optimize nutrition Dexa (decrease inflammation, encourage weaning) Dexa associated with increased risk of adverse neurodevelopmental outcome
92
Prognosis of BOD
pHTN Poor growth Right-sided heart failure May persist into adulthood: Airway obstruction Airway hyperreactivity Emphysema Adverse neurodevelopmental outcome
93
DDx of peripheral cyanosis
Transient (typical) Sepsis Temperature instability
94
Causes of central cyanosis
Deoxygenated Hb Or Abn Hb
95
DDx of abn Hb causing cyanosis
Methemoglobinemia: Reads higher on pulse oximetry than the true level. Alters absorption of red light Carboxyhemoglobinemia: CO-Hb, may not be evident clinically and may not register on pulse oximetry
96
DDx if deoxyhemoglobin
``` Respiratory Cardiovascular Neurogenic Hematologic Sepsis ```
97
Mx of cyanosis
ABG Elevated CO2: respiratory causes Hyperoxia test: If < 150 (cyanotic CHD, possible PPHN) If > 150: likely respiratory/non cardiac cause CXR
98
Diaphragmatic hernia
Often associated with other anomalies Pulmonary hypoplasia PPHT
99
Tx of diaphragmatic hernia
DO NOT BAG MASK VENTILATE Large bore orogastric tube to decompress bowel Stabilization Mx pulmonary hypoplasia Hemodynamic support Surgery when stable
100
Hypoglycemia definition
Glucose <2.6
101
Mx of hypoglycemia
Identify and monitor infants at risk (pre-feed Glucose check) Begin oral feed as soon as possible Ensure regular feeds If significant/symptomatic hypoglycemia: IV glucose If persistent or if no predisposing cause: Sent critical blood work during an episode: ABG, Ammonia, Betahydroxybutorate, Cortisol, FFA, GH, Insulin, Lactate, Urine dipstick for ketones
102
Hypoglycemia RFs
``` Prematurity SGA RDS Maternal HTN GH/Cortisol/EN deficiency Insulin excess HPA axis suppression FFA oxidation defects Galactosemia Sepsis Hypothermia Polycytemia ```
103
RFs for IVH
``` Prematurity (<32 wk) BW < 1500 Need for vigorous resuscitation at birth Pneumothorax Ventilation in preterm Hemodynamic instability RDS Coagulopathy ```
104
IVH screening
Routine head U/S of all preterm infants < 32wk or < 1500 MRI for term, extremely LBW infant
105
Mx of IVH
Supportive: Maintain blood volume Maintain acid-base status Avoid BP fluctuation or CBF fluctuation F/U: serial imaging
106
At which bil level would jaundice be visible?
85-120
107
Factors increasing jaundice severity and duration
``` Prematurity Acidosis Hypoalbuminemia Dehydration Hemolysis ```
108
Disorders causing both conjugated and unconjugated hyperbilirubinemia
Hyperthyroidism Sepsis
109
Physiologic jaundice in term infant
Onset: 3-4d Resolution by 10 d of life
110
Physiology Jaundice in preterm infants
Higher pick | Longer duration
111
Breast-feeding jaundice
Physiologic Due to dehydration Common
112
Breast milk jaundice
Physiologic Onset: 7d of life Peak: 2-3 wk Resolution: By 6 wk
113
RFs for jaundice
``` Asian Native american GDM ABO/Rh incompatibility BF FHx Previous child required phototherapy Birth trauma Prematurity Difficulty establishing breast-feeding Infection Genetic factors Polycythemia Drugs TPN ```
114
Causes of conjugated hyperbil
``` Sepsis Hep B TORCH Galactosemia Tyrosinemia a-1-antitrypsin deficiency Hypothyroidism CF Drugs TPN Idiopathic neonatal hepatitis Biliary/choledochal problems ```
115
Jaundice needing evaluation:
First 24 h of life (always pathologic) Conjugated hyperbil (always pathologic) Rapid rise of unconjugated hyperbil Excessive hyperbil for age/wt Persistent beyond 1-2 wk of age
116
Inv for unconjugated hyperbil
Hemolytic w/u: CBC, Retic, PBS, Blood group (mother/infant), Coombs If unwell baby: Septic workup Also: G6PD, TSH
117
Inv for conjugated hyperbil
``` AST, ALT PTT,PT Alb Ammonia TSH TORCH Septic W/U Erythrocyte Galactose-1PUT Metabolic screen Abd U/S HIDA Sweat chloride ```
118
Predicting occurrence of severe hyperBil
TSB or TCB in all infants between 24-72 hr of life Results should be ploted on predictive normogram
119
Tx of HyperBil
Continue BF, ensure adequate feeds and hydration Pump after feeds Treat underlying Phototherapy (not UV) Exchange transfusion IVIg
120
Contraindication to phototherapy
Conjugated hyoerBil
121
Indications of exchange transfusion for hyperbil
High bil levels Mostly for: Hemolytic disease G6PD deficiency
122
Indication for IVIg in hyperBil
Severe hyperbil, DAT+
123
Level of bil able tu cause kernicterus
340< Lower if: Sepsis, meningitis, hemolysis, hypoxia, acidosis, hypothermia, hypoglycemia, prematurity
124
Sx of kernicterus
15% asymptomatic Early stage: Lethargy, hypotonia, poor feeding, emesis Mid stage: Hypertonia, high-pitched cry, opistotonos, bulging fontanelle, seizures, pulmonary hemorrhage Late stage: Hypotonia, delayed motor skills, extrapyramidal abn (choreoathetoid), gaze palsy, mitral regurgitation, SNHL
125
Biliary atresia presentation
After first week of life Dark urine, pale stool, jaundice Persists > 2 weeks
126
Dx of biliary atresia
Conjugated hyperBil Abd U/S Operative cholangiogram HIDA (bypass if time is critical) Liver Bx
127
Tx of biliary atresia
Surgical drainage Hepato-porto-enterostomy Liver transplantation required in most cases Diet enriched with medium-chain TG Vitamin ADEK
128
Site of involvement in NEC
Terminal ileum and colon
129
RFs for NEC
``` Prematurity Asphyxia Shock Hyperosmolar feeds Enteral feeding with formula Sepsis ``` Protective factor: breast milk, early full enteral feeding
130
Sx of NEC
Onset: 2-3 wk of age Distended abd Increased gastric aspirate/vomitus with bile staining Frank/occult blood in stool Feeding intolerance Diminished bowel sounds Signs of bowel perforation: sepsis, shock, peritonitis, DIC
131
Inv for NEC
``` AXR CBC ABG Lactate Blood culture Lytes ```
132
AXR in NEC
Pneumonitis intestinalis (intramural air) Free air Fixed loops Ileus Thickened bowel wall Portal venous gas
133
Tx of NEC
NPO (7-10d) Vigorous IV fluid Decompression with NGT Supportive therapy TPN AB (ampi, genta+metro if risk of perforation x7-10d) Serial AXR If perforation: peritoneal drain/surgery Surgical resection of necrotic bowel/complications
134
Presentation of Persistent pHTN of the newborn
Within 12 h of life Severe hypoxemia, cyanosis
135
RFs for PPHTN
``` Asphyxia MAS RDS Sepsis Pneumonia Structural abn ``` More common in term/post-term infants
136
Inv for PPHTN
Pre- and post-ductal O2 levels Hyperoxia test ECG Echo
137
Tx of PPHTN
Maintain good oxygenation (SaO2 > 95%) O2 given early and tapered slowly Minimize stress and metabolic demands Maintain nl blood gases Circulatory support Mechanical ventilation NO, surfactant Extracorporeal membrane oxygenation
138
Tachypnea and tachycardia in newborn
RR> 60 HR> 160
139
Inv for respiratory distress in newborn
CXR ABG CBC, BG, B/C ECG
140
RF for newborn pneumonia
Maternal fever Prolonged/premature ROM GBS positive mother
141
RDS RFs
``` Maternal DM PTB Male LBW Acidosis Sepsis Hypothermia Second born twin ```
142
Onset of RDS
First few hours Worsens iver next 24-48 h
143
CXR of RDS
Homogenous infiltrates Airbronchogram Decreased lung volumes May resemble pneumonia Without lungs if severe
144
Prevention of RDS
Prenatal CS if risk of PTB <34 wk Monitor L/S with AC (> 2: lung maturity)
145
Tx of RDS
Resuscitation O2 Vent Surfactant
146
TTN gestational age
Term, late preterm
147
RFs fir TTN
GDM Maternal asthma Male Macrosomia (> 4500) Elective cesarian Short labor Late PTB
148
Onset of Sx in TTN
First few hours of life NO CYANOSIS Retraction, nasal flaring, grunting
149
CXR in TTN
Perihilar infiltrates Wet silhouette Fluid in fissures
150
Prevention from TTN
Avoid elective Cesarian delivery, esp before 38 week GA
151
Tx of TTN
O2 if hypoxic Vent If too tachypneic to feed orally: IV fluid NGT feeding
152
In TTN when is recovery expected?
In 24-72 h
153
Meconium aspiration syndrome GA
Term, post-term
154
RFs for MAS
Meconium stained AF Post-term delivery
155
Onset of MAS Sx
Within hours of life
156
Barrel chest in neonate
Diaphragmatic hernia MAS
157
CXR in MAS
Hyperinflation Patchy atelectasis Patchy/coarse infiltrates Pneumothorax
158
Prevention
If depressed at birth: Intubate and suction below vocal cords Avoidance of factors associated with in utero meconium passage
159
Tx of MAS
Resuscitate Vent O2 Surfavtant Inhaled NO ECMO if PPHN
160
Early onset sepsis in neonate, Definition, transmission
Within 72 h of birth Vertical
161
Early onset sepsis in neonate, RFs
Maternal UTI, GBS+, previous child with GBS infection Maternal fever/leukocytosis/chorioamnionitis Prolonged ROM >18 h PTB
162
Pathogens of Early onset sepsis in neonate,
E.Coli, GBS, Listeria
163
Most common infection in early onset neonatal sepsis
Pneumonia
164
Late onset neonatal sepsis definition
Onset at: 72h-28d Acquired after birth
165
Most common pathogen in Late onset neonatal sepsis
Coagulase negative staph Others: GBS, anaerobes, E.Coli, Klebsiella
166
Most specific lab in sepsis?
WBC < 5
167
Degree of hypovolemia based on age
<2 yr: Mild: 5% (of preloss body wt) Mod: 10% Sev: 15% > 2yr: Mild: 3% Mod: 6% Sev: 9%
168
Pulse changes in different levels of hypovolemia
Mild: Nl, full Mod: rapid Sev: rapid, weak
169
BP changes in different levels of hypovolemia
Mild: Nl Mod: Nl-Decreased Sev: decreased, shock (very late finding)
170
U/O changes in different levels of hypovolemia
Mild: decreased Mod: markedly decreased Sev: anuria
171
Oral mucosa changes in different levels of hypovolemia
Mild: slightly dry Mod: dry Sev: parched
172
Anterior fontanelle changes in different levels of hypovolemia
Mild: normal Mod: sunken Sev: markedly sunken
173
Eyes changes in different levels of hypovolemia
Mild: normal Mod: sunken Sev: markedly sunken
174
Skin turgor changes in different levels of hypovolemia
Mild: nl Mod: decreased Sev: tenting
175
Capillary refill changes in different levels of hypovolemia
Mild: Nl (<3s) Mod: Nl-increased Sev: increased (>3 s)
176
Inv for hypovolemia
``` If mod-sev: Urinalysis Lytes BUN, Cr ABG ```
177
Indications of IV rehydration
Severe dehydration ``` Inability to tolerate ORT: Vomiting Altered mental status Ileus Monosaccharide malabsorption Inability to provide ORT Failure of ORT in providing adequate rehydration ```
178
Tx of mild dehydration
ORT 50 ml/kg over 4 h + ORT for ongoing loss + age appropriate diet after rehydration
179
Tx of moderate dehydration
ORT 100 ml/kg over 4 h + ORT for ongoing loss + age appropriate diet after rehydration
180
Tx of severe dehydration
IV NS or RL, 20-40 ml/ kg bolus over 1 h Repeat if necessary Continue with ORT when stable Replace ongoing loss Age-appropriate diet after rehydration
181
Calculation of maintenance fluid
Per day: 100:50:20 Or Per hour: 4:2:1
182
Common maintenance fluids for children
Should contain dextrose Newborn: D10W First month of life: D5W/0.45 NS + KCl 20mEq/L(if voiding well) ``` Children: D5W/NS + KCl 20 Or D5W/0.45NS + KCl 20 Bolus NS for dehydration ```
183
Na adjustment rate
12 mmol/L/d
184
When to monitor lytes daily in a child being treated for dehydration?
If > 50 % of daily fluid intake is via IV
185
Most common cause of ARF in children
HUS
186
Inv for HUS
``` CBC PBS BUN, Cr Lytes U/A S/C, verotoxin/shiga toxin assay ```
187
Mx of HUS
``` Mainly supportive: Nutrition Ventilation If symptomatic anemia: blood transfusion Dialysis if indicated ```
188
Hematuria definition
RBC > 5
189
Most common cause of GN in children
PSGN
190
GNs with decreased C3
PSGN MPGN SLE Bacterial endocarditis Abscess, Shunt nephritis Cryoglobulinemia
191
GN with normal C3
IgA nephropathy RPGN Anti-GBM disease HSP PAN GPA Goodposture
192
Inv for GN
Urine R&M First morning urine protein/creatinine ratio (nl < 200 mg/mmol) ``` BUN, Cr Lytes ABG CBC Alb C3/C4 ASOT/anti-hyaluronidase/anti-SK/anti-NAD/anti-DNAse B) ANA Anti-DNA ANCA IgA level Anti-GBM Renal Bx ```
193
Indications for renal Bx in GN
Acute renal failure No evidence of strep infection Normal C3,C4
194
Mx of GN
Treat underlying Supportive: Dialysis Proper hydration HTN: Water/salt restriction (watch renal function) Chronic persistent HTN: ACEI, ARB Edema: Salt/fluid restriction +/- Diuretics CS if indicated: IgA nephropathy Lupus nephritis ...
195
Most common cause of nephrotic syndrome
Primary
196
Nephrotic definition
Proteinuria > 50 mg/kg/d
197
Inv for nephrotic
U/A: 3-4+ proteinuria Urine microscopy First morning urine alb/Cr ratio ``` Alb Lipid profile Lytes BUN, Cr Coagulation profile ``` ``` CBC PBS C3/C4 ANA Hep B/C ASOT HIV Renal Bx ```
198
Indications of renal Bx in nephrotic
HTN Gross hematuria Decreased renal function Low C3/C4 No response to CS after 4 wk Frequent relapse (>2/6mo) Presentation before first year of life Presentation after 12 yr
199
PTT in nephrotic
Decreased
200
Mx of nephrotic
Varicella status should be known Oral prednisone 2mg/kg/d up to 12 wk If resistant: Cytotoxic agents Immunomodulators High-dose CS pulse
201
Tx of nephrotic edema
Salt/fluid restriction +/- diuretics If anasarca: Furosemide + alb
202
Tx of nephrotic hyperlipidemia
Resolves with remission Limit fat intake Statin if persistently nephrotic
203
Abn BP
If intravascular depletion: fluid If persistent HTN: ACEI, ARB
204
Diet in nephrotic
No added salt Monitor caloric intake Ca, Vit D if on CS
205
Vaccines for nephrotic
Pneumococcal: at diagnosis Varicella: after remission
206
Child with nephrotic, on CS, exposed to varicella
VZIG + acyclovir
207
Mx of hypercoagulability state in child with nephrotic
Mobilization Avoid intravascular volume depletion and hemoconcentration Prompt sepsis Tx Heparin if thrombi
208
Relapse rate in nephrotic
2/3
209
Definition of HTN
sBP or dBP > 95th percentile on 3 or more occasions
210
Definition of preHTN
sBP or dBP > 90th percentile Or > 120/80 at any age
211
Primary vs secondary HTN
Primary: 90% of adolescent (> 10yr) cases (esp if obese, positive FHx, mild) Secondary: majority of childhood cases
212
RFs for primary HTN
``` Male FHx Obesity OSA African American Prematurity/LBW ```
213
RFs for secondary HTN
Hx of renal Abd trauma FHx of AI dis Umbilical artery cath
214
Signs of secondary hypertentiin
``` Edema Abd bruit Differential 4 limb BP/ diminished femoral pulses Abd mass Goiter Skin changes Ambiguous genitalia ```
215
Inv for HTN
``` Urine dipstick Urine catecholamines Lytes BUN, Cr Renin, aldosterone levels ``` Echo Abd U/S Renal radionuclide scarring Other tests based on findings
216
Mx of HTN
Tx underlying ``` LSM: Wt reduction Exercise Salt restriction Smoking cessation ``` Thiazides Mx of EOD Cosider referral to specialist
217
Mx of hypertensive emergencies
Hydralazine Labetalol Sodium nitroprusside
218
Pediatric BP calculation
sBP: Age x 2 + 90 dBP: 2/3 x sBP
219
Inv for epilepsy
CBC,diff Na, K, Cl, Mg, Ca, BG Toxicology EEG CT/MRI (if FND, not returned to baseline several hours after seizures) LP (if first-time, non-febrile)
220
Cardiac disorders often misdiagnosed as seizures
Hypertrophic CMP Long QT syndrome
221
Infantile spasm
Brief flex/ext 10-30 sec In clusters Developmental delay Onset: 4-8 mo EEG: hypsarrhythmia
222
Tx of infantile spasm
ACTH Vigabatrin BDZ
223
Prognosis of infantile spasm
20% idiopathic with good Tx response 80% metabolic/encephalopathic/neurocutaneous/developmental abn reasons with poor response to Tx
224
Lennox-Gastaut triad
Multiple seizure types Diffuse cognitive dysfunction Slow generalized spikes and slow wave EEG Other features: Onset: 3-5 y Underlying encephalopathy/brain malformation
225
Tx of Lennox-Gastaut
Valp BDZ Ketogenic diet
226
Juvenile myoclonic epilepsy
Onset: 12-16 y AD Esp in morning Frequently presents as GTC EEG: 3.5-6 Hz, irregular spike and wave, increased with photic stimulation
227
Mx of juvenile myoclonic seizure
Lifetime Valp
228
Childhood absence seizure
<30 sec No post-ictal Onset: 6-7 yr Strong genetic predisposition F>M EEG: 3 Hz spike and wave
229
Mx of absent seizures
Valp Ethosuximide
230
Benign focal epilepsy of childhood with Rolandic/Centrotemporal spikes
Focal motor (tongue, mouth, face, upper ext) Usually in sleep-wake transition state Conscious but aphasic post-ictally Onset: 5-10 y EEG: spikes in centrotemporal area, normal background
231
Prognosis of Rolandic seizure
Spontaneous remission in adolescence without sequla
232
Prognosis of absence seizure
Spontaneously resolves or becomes generalized
233
Mx of rolandic seizures
If infrequent: none If frequent: carba
234
Mx of seizures
Education (precautions: buddy system, shower instead of bath...) Indication for meds: > 2 unprovoked, afebrile seizures within 6-12 mo Start with 1 drug and increase dose Switch over to another if not controlled Add a second if not controlled
235
When to D/C AED?
If > 2 yr seizure free, taper over 4-6 mo
236
Indication for ketogenic diet in seizure control
If no response to polytherapy Or Who do not wish to take meds VALP IS CONTRAINDICATED IN CONJUNCTION WITH KETOGENIC DIET: increased hepatotixicity
237
Age of febrile seizure
6mo - 6 yr
238
Features of febrile seizures
M> F Associated illness/fever FHx No Hx of afebrile srizure No evidence of CNS infection/inglammation
239
Typical febrile seizures?
Duration < 15 min GTC No recurrence in 24 h No neurological impairment/developmental delay before/after seizures
240
Atypical/complex febrile seizures?
Duration > 15 min Focal onset or focal features > 1 seizures/24 h Previous neurological impairment or neurological deficit after seizure
241
W/U for febrile seizure
If typical febrile seizures, only determine source of fever Septic W/U: Including LP: Strongly consider if child < 12 mo, Consider if 12-18 mo, only if meningeal signs in child > 18 mo EEG/CT/MRI: only if atypical febrile seizure, or abn neurologic findings
242
Mx of febrile seizures
Counsel and reassure Antipyretics Fluids If high risk of recurrence or prolonged seizure: have rectal or sublingual lorazepam at home Treat underlying cause of fever
243
Prognosis of febrile seizures
No brain damage Very small risk of developing epilepsy 33% chance of recurrence Px with AED NOT RECOMMENDED
244
Seizures with positive family Hx
Juvenile myoclobic epilepsy (AD) Febrile seizures Absence
245
Headache red flags
First and worst headache of their life Sudden onset FND Constitutional Sx Worse in morning Worse with bending over, coughing, straining Change in LOC Sudden mood change Pain wakes pt Fatigue Affecting school attendance
246
Inv for headache
If red flags: CT, MRI
247
Postural movements showing hypotonia
Traction response Axillary suspension Ventral suspention
248
Inv for hypotonia
``` Lytes ABG Blood glucose CK Serum/urine investigations for metabolic etiologies MRI/MRA if indicated EMG, muscle Bx/NCS Chromosomal analysis, genetic testing, Metabolic testing Neuromuscular testing ```
249
Cerebral palsy
Non progressive Central motor impairment Insult to/anomaly of immature CNS 10% intrapartum asphyxia 10% post natal insult Associated with LBW No etiology in 1/3
250
Sx of CP
Delay in motor milestone Developmental delay Learning disability Visual/hearing impairment Seizure Microcephaly Uncoordinated swallow (aspiration)
251
Inv for CP
Metabolic screen Chromosome studies Serology Neuroimaging EMG, EEG Ophthalmology assessment Audiology
252
Mx of CP
Multidisciplinary Orthopedic Symptomatic
253
Signs of URT disease, above thoracic inlet
Inspiratory stridor Suprasternal retraction
254
Croup location
Subglottic laryngitis
255
Croup age
<6 yr Peak 7-36 mo
256
Croup virus
Mostly Parainfluenza
257
Inv for croup
Clinical Dx If atypical presentation: CXR: steeple sign
258
Emergency in croup
Stridor at rest
259
Tx of croup
Dexa, PO 1 dose Racemic epinephrine: nebulized, 1-3 dose, q 1-3 h If unresponsive: intubate
260
The most common pathogen of tracheitis
S. Aureus
261
Dx of bacterial tracheitis
Clinical Definitive Dx: endoscopy
262
Tx of bacterial traceitis
Intubation | IV AB
263
Most common pathogen of epiglottitis
H. Influenza
264
Age of bacterial traceitis
All ages
265
Age of epiglotitis
2-6 y
266
Tripod position
Epiglotitis
267
Inv for epiglotitis
Clinical AVOID EXAMINING THROAT
268
Tx of epiglotitis
Intubation AB
269
Sign of airway obstruction below thoracic outlet
More expiratory sounds Wheezing
270
DDx of wheezing
Asthma: Recurrent wheezing > 6 y Identifiable trigger Bronchiolitis: First episode of wheezing Usually <1 y Recurrent aspiration Pneumonia Foreign body: Acute Unilateral CF: Prolonged Unresponsive to therapy ``` BPD CHF Mediastinal mass Bronchiolitis obliterans Tracheobronchial anomalies ```
271
Most common age for pneumonia
< 1y
272
Pneumonia pathogens
<5 yr : viral
273
CXR of viral pneumonua
Diffuse streaky infiltrates bilaterally
274
CXR of bacterial pneumonia
Lobar consolidation Pleural effusion
275
Mx of pneumonia
Hydration Antipyretics Humidified O2
276
Peak incidence of bronchiolitis
At 6 mo
277
Bronchiolitis and risk if asthms
Increases incidence of asthma
278
Most common etiology of bronchiolitis
RSV
279
Sx of bronchiolitis
Prodrome of URTI Wheezing, crackles, respiratory distress Peak: at 3-4 d
280
Inv for bronchiolitis
CXR if: Severe Poor responsive to treatment Chronic NP swab: IF for viral Ag WBC
281
CXR of bronchiolitis
Air trapping Peribronchial thickening Atelectasis Increased linear markings
282
Tx of bronchiolitis
Self limiting ``` Mild-mod: Supportive: PO/IV hydration Antipyretic Regular/humidified high-flow O2 ``` Sev: Supportive +/- intubation/ventilation +/- ribavirin
283
Indication for ribavirin in bronchiolitis
BPD CHD Congenital lung disease ImmDef
284
Px against RSV
Monthly palivizumab (RSV-Ig) for high-risk group: Infants born before 29 wk GA Infant born before 32 wk with chronic lung disease of maturity Infant with hemodynamically significant heart disease Children with pulmonary abn Neuromuscular disease (impaired ability to clear secretions) Children < 2 yr who are profoundly ImComp Recommended for the 1st year of life. Up to 5 monthly doses. (Nov-Apr)
285
Tx with no benefit in bronchiolitis
CS Bronchodilators Ipratropium bromide
286
Indications for hospitalization of bronchiolitis
O2 sat < 92% Persistent resting tachypnea (>60) and retraction after several salbutamol masks PMHx if: chronic long disease, hemodynamically significant cardiac disease, neuromuscular problem, immunocompromised <6mo unless extremely mild Significant feeding problem Social problem
287
Common causes of pneumonia in neonates
Viral: CMV, HSV Bacterial: GBS, E.Coli, Listeria
288
Tx of pneumonia in neonates
Ampicillin + genta/tobra + erythro if suspect chlamydia
289
Common causes of pneumonia in 1-3 mo
S. Aureus H. Influenza S. Pneumonia B. Pertussis Viral: CMV, RSV
290
Pneumonia Tx in 1-3 mo
Cefuroxime/ampicillin | +/- erythromycin or clarythro
291
Common causes of pneumonia in 3mo-5yr
S. Pneumoniae S. Aureus H. Influenza GAS Viral: RSV, adeno, inf
292
Tx of pneumonia in 3mo-5y
``` Amoxi Or Ampi Or Cefuroxime ```
293
Common causes of pneumonia in >5y
S. Pneumonia H. Inf S. Aureus Viral: influenza, varicella
294
Tx of pneumonia in > 5y
Erythromycin Clarythro Ampi Cefuroxime
295
Acute asthma Mx
O2 (keep O2sat > 94%) Fluid if dehydrated Salbutamol q20 min Ipratropium bromide if severe q20 min Steroid x 5d PO (IV if severe)
296
Chronic asthma Mx (LSM)
Education Emotional support Avoid allergens or irritants Develop action plan Exercise program Monitoring with peak flow meter PFT for > 6 yr
297
Chronic asthma meds:
Reliever therapy: SABA First line controller therapy: low dose of daily ICS Second line controller therapy: <12 yr: mod dose of ICS >12 yr: add Leukotriene receptor antagonist Or LABA If no response to 1st and 2nd line Tx: Injection Immunotherapy
298
SABA dosage in acute Mx of asthma
<20 kg: 5 puff q 20 min x 1 hr >20 kg: 10 puff q 20 min x 1 hr
299
Ipratropium bromide dosage in acute Mx of asthma
<20 kg: 3 puff >20 kg: 6 puff q 20 min
300
Indications for hospitalization of asthma
Ongoing need for supplemental O2 Persistently increased work of breathing B2-agonist needed > q4h after 4-8 h of conventional therapy Pt deteriorates while on systemic CS
301
Acute asthma attack discharge
If pt asymptomatic for 2-4 h after last dose
302
Adequate control of asthma?
Daytime symptoms < 4 d/wk Night time symptoms < 1 n/wk Normal physical activity Mild and infrequent exacerbations No work/school absenteeism Need for B-agonist < 4 doses/wk FEV1 or PEF > 90% of personal best PEF diurnal variation < 10-15%
303
Antenatal bowel perforation
CF
304
Microorganisms causing recurrent chest infection in CF
S. Aureus P.aeroginosa H. Influenza
305
Inv for CF
Sweat chloride test x2 (abn: >60 mEq/L) 3d fecal fat collection Genetic testing if sweat chloride test was equivocal Sputum S/C CXR
306
False negative sweat chloride test
Technical problem Malnutrition Skin edema Mineralocorticoids
307
False positive sweet chloride test
Malnutrition Atopic dermatitis Hypothyroidism Hypopara Glycogen storage diseases Adrenal insufficiency G6PD Kleinfelter Sx Technical issues Autonomic dysfunction Familial cholestasis syndrome
308
Mx of CF
High calorie diet Pancreatic enzymes Fat soluble vitamins supplementation ``` Chest disease: Chest physio Postural drainage Exercise Bronchodilators Aerosolized DNAase Inhaled hypertonic saline AB (depending on sputum C&S) Lung transplantation ``` Genetic counseling
309
Inv for rheumatologic diseases
``` CBC, diff Blood smear ESR, CRP Xray ANA RF B/C Viral/bacterial serology CK PTT SCD screening Igs Complement U/A Synovial fluid (cell count, gram stain, culture) TB test Imaging BMA Slit lamp exam ```
310
Growing pain age
2-12 yr M=F Dx of exclusion
311
Characteristics of growing pain
Intermittent Non-articular Normal PEx Pain at night Often bilateral Calf, shin, thigh Short-lived Relieved by heat, massage, mild analgesics Asymptomatic during day Well No functional limitation Possible FHx
312
Mx of growing pain
No lab if typical presentation Supportive Reassurance
313
Red flags for limb pain
Fever Pinpoint pain/tenderness Pain out of proportion to degree of inflammation Night pain Wt loss Erythema
314
Age of transient synovitis of the hip
3-10 yr M> F Rt> Lt
315
Sx of transient synovitis of hip
Afebrile/low fever. Not toxic Pain in hip, knee (referral) Painful limp Full ROM Pain not disabling Gradually worsens over few days Can be sudden Resolves over 7-10
316
Inv for transient synovitis
WBC ESR, CRP Joint U/S (to see effusion) If suspicious for septic arthritis: aspirate joint If suspicious for osteomyelitis/periarticular pyomyositis: MRI Dx of exclusion
317
Tx of transient synovitis of hip
Symptomatic Anti-inflammatory meds Usually resolves within 24-48 h
318
Complication of transient synovitis of hip
Legg-calve-perthes
319
Septic arthritis pathogen in neonates
GBS, GNB, S. Aureus
320
Septic arthritis pathogen in 1-3mo
``` Strep Staph H. Inf GBS GNB ```
321
Septic arthritis pathogen in child
S. Aureus S. Pneumoniae GAS
322
Septic arthritis pathogen in adolescents
S. Aureus S. Pneumoniae GAS N. Gonorrhea
323
Septic arthritis pathogen in SCD
S. Aureus S. Pneumoniae GAS Salmonella
324
Tx of septic arthritis in neonate
Cloxa + genta Or Cloxa + cefotaxime
325
Tx of septic arthritis in 1-3mo
Cloxacillin + cefotaxime/cefuroxime
326
Tx of septic arthritis in child
Cefazolin OR cloxa OR clinda
327
Tx of septic arthritis in adolescent
Ceftriaxone/cefixime + azithro
328
Tx of septic arthritis in SCD
Cefotaxime
329
JIA Dx
At least 1 joint At least 6 wk Age < 16 yr Exclusion of other causes Classification by features in the 1st 6 mo of disease
330
Still’s disease (systemic arthritis)
M=F Fever spikes: Once/twice daily >38.5 At least 2 d/wk Unwell during fever episodes Rash: Erythematous salmon-colored LAP HSM Leukocytosis Thrombocytosis Anemia Serositis Arthritis: May occur weeks to month later High ESR, CRP
331
Oligoarticular arthritis
1-4 joints Onset < 5 yr F>M Large joints: knee(most common), elbow, wrists ANA+ (60-80%) RF- Asymptomatic anterior uveitis
332
Most common type of JIA
Oligo
333
Complications of oligoarticular JIA
Knee flexion contracture Quadriceps atrophy Leg length discrepancy Growth disturbance Uveitis
334
Polyarticular arthritis
ANA+ in 50% Uveitis in 10% ``` RF negative (usually negative): Onset: 2-4 yr, 6-12 y F>M Symmetrical involvement Large to small joints of hands and feet, TMJ, cervical spine ``` ``` RF positive: Late childhood/early adolescence F>M Severe Rapidly destructive Symmetrical Large and small joints Reumatoid nodules Unremitting Persists into adulthood ```
335
Enthesitis-related arthritis
Late childhood/adolescence M>F Enthesitis/arthritis Wt-bearing joints (esp hip, intertarsals) Risk of ankylosing spondylitis in adulthood
336
Psoriatic arthritis
Onset: 2-4 yr, 9-11 yr F>M Dactylitis Nail pitting FHx of pso in 1st degree Asymmetric/symmetric small/large joints involvement
337
Mx of JIA
Exercise: To maintain ROM, muscle strength ``` OT/PT Social work Orthopedics Ophthalmology Rheumatology ``` 1st line meds: NSAIDs Intra-articular CS 2nd line: DMARDs (MTX, Sulfasalazine, leflunamide) CS (acute Mx of severe arthritis, systemic symptoms, topical for eye) Biologics
338
Reactive arthritis
Typically the knee Following salmonella/shigella/yersinia/campylo/chlamydia Or Following Strep
339
Highest incidence of lyme in children at age?
5-10 yr
340
SLE
F>M More commonly Age>10 ``` Children have: More active disease More likely to have renal disease More intensive drug therapy Poorer prognosis ```
341
Most common vasculitis of childhood
HSP
342
Peak incidence of HSP
4-10 yr M>F
343
How long after URT infection does HSP happen?
1-3 wk
344
HSP clinical triad
Palpable purpura Abd pain Arthritis
345
Scrotal swelling
HSP
346
HSP arthritis
Large joints
347
Renal involvement in HSP
Microscopic hematuria Proteinuria HTN RF (<5%) IgA nephropathy
348
Inv for HSP
U/A (blood, ACR) Urea, Cr Lytes Alb IgA (elevated) Skin/renal Bx U/S (intussusception, scrotal pain/swelling) R/O other AI conditions
349
Mx of HSP
Mainly supportive: Elevation for edema... Monitor proteinuria, BP q mo x 6 mo Check for renal disease Anti-inflammatory meds for joint pain CS for selected pts Immunosuppressive therapy if severe renal disease
350
Prognosis of HSP
Self-limited Resolution within 4 wk Recurrence in 1/3 Long-term prognosis depends on severity of nephritis
351
Most common cause of acquired heart disease in children in developing countries
Kawasaki
352
Size of vessels involved by Kawasaki
Medium
353
Peak age of kawasaki
3mo-5yr Asian>Black>Caucasians
354
Dx criteria of Kawasaki
Fever persisting 5 d or more And 4 of: Bilateral, non-exudative conjunctival injection Oral mucous membrane changes Changes of peripheral ext Polymorphous rash Cervical LAP > 1.5 cm USUALLY UNILATERAL
355
Atypical Kawasaki
Fever at least 5 d Plus 2-3 of symptoms ESR, CRP
356
Mx of Kawasaki
Initial therapy: IVIg + high dose ASA Once afebrile > 48h: Low-dose of ASA until plt normalize. Longer if coronary artery involvement Baseline echo and F/U echo at 2,6 wk
357
Time of IVIg treatment to prevent coronary artery disease in Kawasaki
10 d
358
RFs for coronary artery disease in Kawasaki
Male Age<1 yr, > 9yr Fever > 10d Asian or hispanic Thrombocytopenia Hyponatremia

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