Pediatrics Flashcards
Persistent pulmonary HTN can be suspected in what group - preterm, term, postterm
What does the Xray look like?
Term and Post-term neonates with cyanosis
XRay: Clear lungs with decreased pulmonary vasculature
Transient Tachypnea of the Newborn can be suspected in what group - preterm, term, postterm
What does the Xray look like?
Term
XRay: Bilateral perihilar linear streaking
Premature infants with grunting, flaring, retractions, central cyanosis immediately after birth =
Treatment?
Respiratory Distress Syndrome
Treatment = continuous positive air pressure ventilation
Acrocyanosis =
Blue extremities + Pink body
- common
- benign
- may last for 1-2 days
severe coughing paroxysms + apparent subcutaneous emphysema -> need to rule out _
Pneumothorax
- it can also cause other things but a pneumothorax would be the most emergent
- get a chest xray to rule out
subcutaneous emphysema = gas or air under the skin that usually comes from the chest, feels like rice crispies
How is RSV different in smaller kids vs older kids
Can present with URI symptoms (rhinorrhea, nasal congestion) + lower tract symptoms (wheezing, crackles, respiratory distress)
Older kids only get the URI symptoms
Main risks:
- apnea
- respiratory failure
- recurrent wheezing throughout childhood
RSV -> bronchiolitis
Treatment for Epiglottitis
First priority is to secure the airway
- keep child calm
- endotrachial intubation in the OR
- if that doesn’t work, emergency trachyotomy
What is epinephrine’s mechanism?
Beta-2 agonist = bronchodilation, decreases systemic release of inflammatory mediators
Alpha-1 agonist = vasoconstriction
neonate with scaphoid abdomen (concave), barrel chest, polyhydramnios in utero, no breath sounds on L,, hypoxia on room air =
Management =
Congenital Diaphragmatic Hernia
First step in management = endotrachial intubation
Second step = gastric tube - decompresses the stomach and bowel
Are men with CF fertile?
No - due to obstructive azoospermia
- insipissated mucus in the fetal genital tract obstructs the developing vas deferens -> congenital bilateral absence
- spermatogenesis is normal but the sperm cannot be ejaculated
Genetics of CF?
AR
SGA complications for the baby:
- Hypoxia
- Perinatal asphyxia
- Meconium aspiration
- Hypothermia
- Hypoglycemia
- Hypocalcemia - caused by decrease Ca transfer across the placenta
- Polycythemia - caused by increased Epo secretion in response to hypoxia
Pills/tablets that are radio-opaque on XRay
-Iron
What to do if parents refuse life-saving treatment for their child?
Obtain court order to mandate treatment
Contraindications to rotavirus vaccine: (4)
- Anaphylaxis
- Hx of intussusception
- Hx of uncorrected congenital GI malformation
- SCID
note: Do no give rotavirus older than 8 months 0 days old
Chronic Granulomatous Disease prophylaxis (2)
- TMP/SMX
- Itraconazole
- Rapid onset of facial edema following infection, trauma, dental procedure without a rash
- Normal C1q level
- Depressed C4 level
Hereditary angioedema
-C1q levels are depressed in acquired
For stable preterm infants, vaccines should be given based on (chronological/gestational) age.
One exception:
Given based on chronological age
Exception: weight should be >2 kg (4 lbs 6 oz) before first vaccine (Hep B)
EKG changes are indicative of what process in a teenager:
- Tall R wave in aVL + Deep S wave in V3
- Inverted T waves in I, aVL, V4, V5, V6
Hypertrophic cardiomyopathy
Prevalence 1/500
Commotio cordis
Development of a fatal V fib after sudden blunt chest wall trauma
- often seen in basketball
- occurs in athletes with no prior cardiac disease
On EKG, infants have physiologic findings
-L/R axis deviation?
R axis deviation is physiologic
-infants have a larger R ventricle due to the PDA shunting the blood away from the lungs, thus the R ventricle being responsible for pushing blood to the systemic circuit
Tricuspid Valve Atresia requires 2 other structural defects to survive
- ASD: results in increased blood flow to RA -> RA enlargement -> peaked P waves
- VSD: results in holosystolic murmur loudest at the L lower sternal border
What happens to the Right Ventricle and R sided circulation in Tricuspid Valve Atresia?
Lack of blood flow from RA->RV results in a hypoplastic RV and consequently underdevelopment of the pulmonary valve and artery
Will see decreased pulmonary markings on CXR
EKG of a 1 week old
- L axis deviation
- small/absent R waves in V1-V3
Tricuspid Valve Atresia
“Boot shaped heart” on CXR
Tetralogy of Fallot
4 characteristics of Tetralogy of Fallot
1) RV Outflow Tract Obstruction - Plumonary stenosis or atresia
2) RV hypertrophy
3) Overriding aorta
4) VSD
Jervell-Lange-Neilsen Syndome
Inherited cause of Long QT syndrome
- molecular defect in K channel
- AR
- associated with sensorineurial deafness
3 electrolyte derangements that can cause Long QT Syndrome
- Hypocalcemia
- Hypokalemia
- Hypomagnesemia
Romano-Ward Syndrome
Inherited cause of Long QT syndrome
- molecular defect
- AD
- NOT associated with deafness
Kawasaki Disease treatment
Usually self-limited but treatment is used to prevent cardiac complications
-Aspirin + IVIG
Sandpaper rash that spares the palms and soles =
Rash of scarlet fever
Most common cause of secondary hypertension in children =
Fibromuscular dysplasia
- R renal artery worse than L renal artery
- hum/bruit heard at the costovertebral angle due to well developed collaterals
- string of beads appearance on angiography
DiGeorge Syndrome clinical features (5)
CATCH-22
- C = conotruncal cardiac defects
- A = abnormal facies
- T = thymic aplasia/hypoplasia
- C = cleft palate
- H = hypocalcemia
- 22 = chromosome 22q11.2 deletion
Loud first heart sound + Mid diastolic rumble =
Mitral stenosis
-almost always due to Rheumatic Fever
Causes of pediatric viral myocarditis (2)
- Coxsackie B
- Adenovirus
Viral prodrome -> Heart failure
What effect do these things have on preload?
- Valsalva
- Abrupt standing
- Nitroglycerine
Decreases preload
At what grade murmur do you need to do a work up?
Grade I-II = no workup needed
Grade III+ = workup
LH and FSH levels in central vs peripheral precocious puberty
Central: early GnRH activation -> elevated LH/FSH
Peripheral: gonadal or adrenal release of excess sex hormones -> low GnRH, low LH/FHS
Treatment for idiopathic precocious puberty
GnRH agonist therapy
-goal is to increase adult height
15 yo had a URI last week and now is presenting with metabolic acidosis, polyuria, decreased level of consciousness, dehydration, diffuse abdominal pain
DKA -> increased release of catecholamines, cortisol, glucagon -> hyperglycemia, ketonemia, osmotic diuresis -> net renal loss of K and K body stores depleted
Isolated premature adrenarche is a risk factor for the development of what 3 syndromes =
- PCOS
- T2DM
- Metabolic Sydrome
Virilazation of female infants + Salt Wasting =
21 hydroxylase deficiency
-build up of 17 hydroxyprogesterone
swollen + fluctuant tonsil uvula deviated to the opposite side "hot potato" voice trismus drooling
Peritonsillar abscess
Growth failure + recurrent respiratory infections + steatorrhea =
Cystic Fibrosis
-GI manifestation - pancreatic insufficiency - leads to inability to absorb fats and vitamins DEAK
Down Syndrome associated GI defects (3)
- Duodenal atresia
- Hirschprung disease
- Imperforate anus
CF associated GI defects (1)
Meconium ileus
-usually occurs at terminal ileum
What should be used for IV bolus rehydration in children?
20 mL/kg normal saline IV (isotonic fluid)
-add dextrose to maintenance fluid
Patients with Beckwith Weidmann Syndrome are at increased risk for what 2 complications?
- Hepatoblastoma
- Wilms Tumor
Screening abdominal ultrasounds and alpha-fetoprotein levels are routinely monitored
Macrosomia Macroglossia Hemihyperplasia Umbilical Hernia/Omphalocele Hypoglycemia
Beckwith-Weidmann syndrome
- chr 11p15
- encodes insulin-like growth factor
Are women with CF infertile?
Only 20% of CF women have fertility problems
-secondary amenorrhea from malnutrition + thick cervical mucus obstructing sperm pathway
Describe the dermatitis of pellagra:
looks like a sunburn and occurs in sun exposed areas
GI complaints + Glossitis + Watery diarrhea + rash = what vitamin deficiency?
Niacin (Vit B3) - Pellagra
- diarrhea
- dermatitis
- dementia
- death
How to distinguish milk-protein allergy in an infant? (4)
Treatment?
- regurgitation
- eczema
- poor weight gain
- painless bloody stools
Treatment: switched to hydrolyzed formula OR mom should eliminate all dairy and soy from her diet
-NOTE: most formulas are cow milk protein based
What is the only absolute infant contraindication to breastfeeding?
Galactosemia
Liver biopsy of Reye Syndrome?
Lab findings?
Microvesicular fatty infiltration
Increased AST, ALT, PT, INR, PTT, ammonia
Metabolic derangements of pyloric stenosis
Hypochloremic, hypokalemic metabolic alkalosis
Before surgical treatment it is important to rehydrate and fix electrolyte abnormalities
Intussusception causes:
- less than 2 yo
- greater than 2 yo
less than 2 yo: most likely idiopathic
greater than 2 yo: most likely a pathological lead point - Meckles diverticulum
if patient had a preceding viral infection (gastroenteritis), inflamed peyer’s patches may serve as lead point
Triple bubble sign + gasless abdomen on X Ray =
Jejunal atresia
- occurs often due to vascular accident in utero (ex: cocaine)
- bilious vomiting
- abdominal distension
pneumatosis intestinalis on Xray
extravasation of bowel gas into the damaged bowel wall
- occurs in Necrotizing Enterocolitis (NEC)
- may lead to pneumoperitoneum, strictures, short bowel syndrome or death
Children with Cyclic Vomiting Syndrome usually have a family history of _
migraines
Therapy with anti-emetics and anti-migraine medications (sumitriptan) is often helpful
VACTERL
Vertebral anomalies Anal atresia Cardiac anomalies Tracheo-Esophageal fistulas Renal anomalies Limb malformation
3 risk factors for constipation in children
- dietary changes - solid foods, cow’s milk
- toilet training
- school/daycare entry
Cause and location of gastroschisis
cause = vascular insult resulting in bowel herniation location = lateral to umbilical cord
will see elevated maternal serum alpha-fetoprotein
CHARGE
Coloboma Heart defects Atresia choanae Retardation of growth/development Gentio-urinary anomalies Ear abnormalities/deafness
Treatment for and cause of unilateral uncomplicated acute lymphadenitis
Most common cause of unilateral is Staph aureus or Strep pyogenes
Treatment is clindamycin
Treatment of localized Lyme disease in a 5 year old (rash only)
Oral amoxicillin or cefuroxime
Doxycycline is contraindicated in children
3 main causes of acute bacterial sinusitis
First line treatment
- Strep pneumoniae
- Nontypable H flu
- Moraxella catarrhalis
Treatment = Amoxicillin/Clavulanate
neonate who develops rhinorrhea and a desquamating maculopapular rash on buttocks/feet in the first 48 hours has what congenital infection?
Congenial syphilis
- transplacental transmission
- snuffles (rhinorrhea)
- maculopapular rash that may involve palms and soles that desquamates or becomes bullous
- abnormal long bone radiographs (metaphyseal lucencies)
Treatment: penicillin - curative and prevents late manifestations
At what size should you be worried about a lymph node?
> 2cm
antibiotic prophylaxis for a cat bite
Amoxicillin/Clavulanate
-covers for Pasturella multiocida and oral anaerobes
Most common cause of CF-related pneumonia by age
less than 20 yo =
20+ yo =
less than 20 yo - Staph aureus
20+ yo - Pseudomonas
Patients with sickle cell disease are at risk for sepsis from what 3 bacteria?
- Strep pneumo
- H flu
- N meningiditis
Acute onset high grade fever and respiratory distress (impaired inspiration)
Drooling
Muffled voice
Keeping neck hyperextended provides some relief
Epiglottitis
- “hot potato” voice
- hyperextention of the neck increases airway diameter
- obstruction is the most concerning complication
- may require nasotrachial intubation
Infant with chlamydial conjunctivitis
- timing
- treatment
timing = 5-14 days treatment = oral erythromycin
note: oral erythromycin in infants increases the risk of pyloric stenosis. this is also the treatment for chlamydial pneumonia (develops at 4-12 weeks).
Infant with gonococcal conjunctivitis
- timing
- treatment
timing = 2-5 days treatment = IM or IV ceftriaxone or cefotaxime
The erythromycin ointment put on infants eyes within 1 hour of birth is to prevent _
Gonococcal conjunctivitis
Most common leukemia in children?
ALL
Most common primary bone tumor in children and young adults?
Osteosarcoma
- Codmann’s triangle - periosteal elevation
- Sunburst pattern
- Elevated alk phos and lactate dehydrogenase
What bone lesion?
Sclerotic lesion in the cortex of a long bone
Pain worse at night
Pain is relieved with NSAIDs
Osteoid osteoma
What is the organ most affected by people with sickle cell trait?
Kidney
- painless hematuria
- isothenuria (nocturia or polyuria - impaired concentrating ability)
- splenic infarction at high altitudes
macrocytic anemia + low reticulocyte count + congenital anomalies (short stature, webbed neck, triphalangial thumbs) + elevated fetal Hb levels + pallor in neonatal period =
Diamond-Blackfan Syndrome
- intrinsic defect in erythroid progenitor cells which results in increased apoptosis
- therapy = corticosteroids
pancytopenia + macrocytosis + cafe au lait spots + absent thumbs + short stature + horseshoe kidney =
Fanconi anemia
- AR
- caused by chromosomal breaks
- dx by age 8 yo
Treatment of stroke like symptoms in a sickle cell patient
exchange transfusion
-it does not reverse the initial sickling/vascular event but it reduces the number of sickled cells in circulation therefore reducing the likelihood of another event
neonatal polycythemia is defined by
hematocrit greater than 65% in term infants
caused by:
-intrauterine hypoxia
-erythrocyte transfusion
Eosin-5-maleimide test (flow cytometry) and Acidified glycerol lysis test are used to dx what?
Hereditary Spherocytosis
Pharmacotherapy for monosymptomatic enuresis
- first line
- second line
First line = desmopressin
Second line = TCAs
What renal disease is associated with HBV?
- Membranous nephropathy (nephrotic)
- Membranoproliferative glomerulonephritis (nephrotic or nephritic)
What renal disease is associated with HIV?
Focal Segmental Glomerulosclerosis (nephrotic)
5 Kawasaki Disease diagnostic criteria
Need 4/5 for dx
- fever for at least 5 days
- bilateral conujunctivits - spares limbus, nonexudative
- rash
- extremity changes - erythema, edema, desquamation
- oral mucosa changes - strawberry tongue, fissured lips, erythema
- cervical lymphadenopathy - greater than 1.5 cm, unilateral
child with back pain + progressive neurological dysfunction (new urinary incontinence) + palpable step off at the lumbosacral area
Spondylolisthesis
- forward slip of the vertebrae
- usually at L5 over S1
Down syndrome child who presents with upper motor neuron findings
Atlantoaxial instability = excessive laxity in the posterior transverse ligament of the spine which results in increased mobility between the atlas (c1) and the axis (c2)
Macrocephaly + feeding problems since birth + numerous café au lait spots + short stature + learning disabilities
Neurofibromatosis 1
-Chr 17 = NF1 tumor suppressor gene = protineruofibromin
Greatest risk factor for CP
Premature birth before 32 weeks gestation
-results in spastic diplegia
Teenager who was adopted + myotonia + facial weakness + foot drop + dysphagia + testicular atrophy =
Myotonic dystrophy
- AD
- CTG repeat in DMPK gene on chr 19
Child presenting with sudden onset hemiplegia + hemianesthesia + neck pain. Earlier in the day while brushing his teeth he fell and the toothbrush hit the back of his throat.
Traumatic carotid injury resulting in internal carotid artery dissection
- Internal carotid arteries are located directly posterior and lateral to the tonsillar pillars
- Caused by minor oropharyngeal trauma, neck strain/manipulation, penetrating trauma
- Dx confirmed with CT or MR angiography
Fever + severe nocturnal or morning headaches + focal neurological changes = classic triad of _
brain abscess
Medulloblastoma symptoms
- obstructive hydrocephalus = morning/night headaches, night vomiting
- cerebellar dysfunction = truncal ataxia, incoordination
Medulloblastoma is a posterior fossa tumor. Most often occuring in the cerebellar vermis.
T wave inversion ddx: (5)
- Myocardial infarction
- Myocarditis
- Old pericarditis
- Myocardial contusion
- Digoxin toxicity
First line OCD treatment
First line = cognitive behavior therapy + high dose SSRI
If resistant to SSRI treatment, then antipsychotic
First line Tourette’s treatment
First line = second generation antipsychotic (Risperidone)
Second line = alpha adrenergic receptor agonist (Clonadine, Guanfacine)
Electrolyte disturbances in anorexia nervosa (2)
- Hypokalemia
- Hypophosphatemia
TM with peripheral granulation + skin debris. That same ear has been draining for an extended period of time despite antibiotics.
Choleosteatoma = abnormal growth of squamous epithelium in the middle ear
- congenital
- acquired - caused secondary to chronic middle ear infections
Acute Otitis Media causes (3)
Treatment (2)
Causes:
- Strep pneumo
- H flu nontyepable
- Moraxella
Treatment: 10 days
- oral Amoxicillin
- oral Amoxicillin/Clavulanate
Adolescent boy + nasal obstruction symptoms + nasal mass + frequent nosebleeds + erosion of nasal bone on CT =
juvenile angiofibroma
- composed of many blood vessels that can easily bleed
- benign but locally invasive
- needs a specialist
infant who has inspiratory stridor only when supine
Laryngomalacia
- chronic stridor in infants
- caused by floppy supraglotting structures that collapse during inspiration
- spontaneous resolution by 18 months
- dx via clinical + flexible laryngoscopy
follicular conjunctivitis + pannus (neovascularization) in the cornea
Trachoma
- C. trachomatus serotype A-C
- major cause of blindness worldwide
- concurrent infection of nasopharynx leading to nasal discharge
- treatment: topical
Most common predisposing factor for orbital cellulitis is _
bacterial sinusitis
3 pill emergency contraception options
- Levonorgestrel oral = progestin, delays ovulation [first option]
- Ulipristal oral = antiprogestin, delays follicular rupture and impairs implantation
- Combined OCP = progestin, delays ovulation, not as effective
moderate to severe bleeding from acute abnormal uterine bleeding (AUB) caused by ovulation dysfunction in an adolescent is treated with
high dose IV or oral estrogen
-promotes regrowth of the endometrium over the denuded epithelium
cause of a young girl’s irregular menstrual cycles
- immaturity of the hypothalamic-pituitary-gonadal axis
- not enough hormones to induce correct ovulation (too low GnRH)
marfanoid habitus + mental retardation + downward lens dislocation + fair complexion + thromboembolic events =
Homocystinuria
- AR
- deficiency of cystathionine synthase
marfanoid habitus + heart issues (aortic root dilation) + upward lens dislocation =
Marfan syndrome
- AD
- mutation in fibrillin-1 gene
Turner syndrome patients are at risk for developing _
Osteoporosis - perhaps due to the low E levels from gonadal dysgenesis
Gold standard for dx Muscular Dystrophy
Genetic testing
- X linked R
- deletion of dystrophin gene (Xp21)
Kallmann Syndrome genetics
Xlinked R
-46 XY
How to prevent the spread of salmonella?
Cook meats thoroughly
Click/clunk of hips in a newborn 2 causes, 4 risk factors
- shallow, poorly developed acetabulum
- laxity of supporting ligaments
risks:
- female
- first born
- breech
- family hx of developmental dysplasia of the hip (DDH)
mental status changes that occur during ketoacidosis is caused by _
cerebral edema
J wave on an ekg =
hypothermia
3yo comes in for rapid breathing and can’t catch his breath. pulse = 100, RR = 30, BP=120/80. lungs clear. slight hyperresonance on right chest. decreased breath sounds on right. x-ray shows slight overexpansion of right lung compared with left. no infiltrates or effusions.
What has happened?
aspiration
do a bronchoscopy to evaluate
newborn with HIV+ test - what is the treatment?
6 weeks of AZT started within 12 hours of delivery
age group for legg-calve-perth disease
age group for slipped capital femoral epiphysis
4-10 yo
9-14 yo
Apt test
Distinguishes maternal blood from fetal blood via hemoglobin
Treatment for seborrheic dermatitis
topical steroids + special shampoo
subglotting edema in a child who is having trouble breathing =
croup
A child has ingested a caustic liquid.
What is the next step after stabilizing airway?
fiberoptic endoscopy and nothing NPO
testicular swelling + absent cremasteric reflex + scrotal or abdominal pain
testicular torsion
treatment: surgery ASAP
microscopy of Hashimoto thyroiditis
lymphocytic infiltrate
child with + PPD skin test + negative CXR + appears well
treatment?
Isoniazid only
acute otitis media VS otitis media with effusion
acute otitis media occurs more rapidly with signs and symptoms of inflammation
otitis media with effusion has no signs or symptoms of acute inflammation, generally asymptomatic
blood under the periostium
cephalohematoma
blood under the galea aponeurotica
subgaleal hemorrhage
when does infantile colic subside?
4 months
RBC casts
glomerulonephritis
MCV less than 80 + anemia + target cells in periphery
thalassemia
First step in management for a kid in DKA?
1) replace fluids and potassium
2) insulin
What keeps a PDA open?
Prostaglandin E1
