Pediatrics Flashcards
Essential SIDS safety to educate the parents on?
Sleep on back, don’t share beds, stop smoking
When is there a social smile?
2 months
When can a kid hop on one foot?
4 years
At about what age should a kid be able to walk?
1 year
When can a kid skip?
5 years
What type of child behavior is indicative of abuse (in regards of child to hospital staff)?
Seeking comfort from you rather than parents
When is there separation anxiety?
6-12 months (stranger at 6, separation at 12)
Talk about the speech relative to age
1:1 (add one word to the sentence for every year)
When is there stranger anxiety?
6-12 months (stranger at 6, separation at 12)
Dirty wound with unknown tetanus status. What do you do?
vaccine and tetanus immunoglobulin
Dirty wound. Tetanus booster greater than 5 years ago but received full series. What do you do?
Booster only
Child has uncontrollable coughing spells with inspiratory “whoop” sound between coughs. What’s the dx?
Pertussis
How many doses of MMRV do you need?
Two - one at 12-15 months and one at 4-6 years
A child received two doses of the hep B vaccine but then hasn’t been seen in 2 years. Do you need to restart the series?
No - finish the series with one time dose (need total of 3)
Dyspnea, dysphagia, grey pseudomembrane, what’s the dx?
Diptheria
How do you treat diphtheria (3 A’s)?
Airway, antibiotics, antitoxin
What is an absolute contraindication to giving another dose of the DTaP vaccine?
encephalopathy within 7 days of a previous dose
Which vaccines are live attenuated?
Intranasal flu, MMRV
What group shouldn’t get live-attenuated vaccines?
Immunocompromised (or pregnant!)
What are the 3 types of flu vaccines? Name them and their individual contraindication
1) Inactivated IM injection: severe egg allergy (though not anymore); 2) live intranasal - immunocompromised; 3) recombinant - anaphylaxis to its components
Vaccines associated with egg allergy?
Yellow fever (influenza and MMR ok to use)
Can you give HPV vaccine to a sexually active teen?
Yes - it will provide immunity as long as they’re not already infected (start as early as 9)
Post-exposure interventions for varicella. Who gets what?
varicella vaccine for all children; VZIG for immunocompromised pts
Difference btwn DTaP and Tdap?
DTaP is for kids (big D for big dose)
Tdap is for adults
Mom has hep B and is delivering baby, what do you do?
Hep B immunoglobuline and vaccine for baby
Dirty wound, greater than 3 lifetime doses, less than 5 years since the less one - what do you do?
Send home
Mom has unknown Hep B status and is delivering baby, what do you do?
Hep B vaccine for baby now; check mom’s status; give HBIG to any if cannot obtain in timely fashion
Ill-appearing child with croup that does not respond to racemic epinephrine. What is your likely alternative diagnosis?
Bacterial tracheitis
How can you prevent epiglottitis?
Hib vaccine
Barking cough, severe dyspnea improved by arrival, organism that causes it?
Parainfluenza virus (croup)
If you seen an abscess (retropharyngeal or peritonsilar), what should you do?
Incision and drainage (it actually doesn’t matter that it’s an ENT abscess - same tx) + antibiotics
Drooling, tripoding, high fever, very sick looking - what is it and what do you do?
Epiglottitis, intubate before anything else
Unvaccinated child with toxic-appearance, drooling, and stridor. Dx? Causative organism?
Epiglottitis; Hib (haemophilus influenza)
What does the X-ray show for bacterial tracheitis?
steeple sign (sublottic narrowing) - see the same thing in parainfluenza (croup)
Barking cough, severe dyspnea improved by arrival; dx?
croup
Hot potato voice (nasal sounding) and you can see the tonsils shifted to the side, dx?
peritonsillar abscess
Hot potato voice (nasal sounding) and you can’t see anything in the mouth but neck is swollen and tender - dx?
retropharyngeal abscess
How do you make the dx of asthma?
PFTs, bronchodilator reversibility, methacholine inducibility
What’s the most common virus responsible for bronchiolitis?
RSV (NOT parainfluenza)
How do you treat an acute asthma exacerbation?
Albuterol/ipratropium and steroids (maybe Magnesium, maybe subQ epi); get peak flow rates before and after
Immigrant child without any prenatal testing has salty sweat and failure to thrive, what’s the diagnosis?
Cystic fibrosis
Child has sudden onset dyspnea after being left alone for “just a few minutes” - what do you do?
CXR AP and lateral (foreign body airway obstruction)
What are some things you can tell parents to help their kids with asthma?
remove pets, carpets, parental smoking
Cystic fibrosis kids get respiratory infections and there are two big causative pathogens. What are they?
Pseudomonas (trending down) and staph aureus (trending up)
How do you diagnose cystic fibrosis?
sweat chloride test (gt 40 for neonates, gt 60 for older)
What’s the first step in treating asthma?
SABA (albuterol)
What do you add on after a SABA in chronic asthma tx?
SABA + ICS (inhaled corticosteroid)
What do you add on after a SABA and ICS in chronic asthma tx?
SABA, increase ICS, then can add LABA
A ___ should not be used without an inhaled corticosteroid in asthma prevention, or else asthma related death increases
LABA
How do you diagnose BRUE (age, duration, and 4 things)?
(brief resolved unexplained event) - combination of change in color, breathing, tone, or responsiveness. Less than 1 year of age. Less than 1 minute. No other causes on H&P.
BRUE age cut off?
1 year of age
What’s the difference btwn ALTE and BRUE?
ALTE relies on caregiver concern, BRUE relies on timing and duration
Features of ALTE (apparent life threatening events)?
combination of change in respiration (choking, gagging, apnea), color change (red, blue, pale), and muscle tone change (hyper or hypotonic); also need parental concern
SIDS isn’t associated with BRUE. What ahs it been associated with?
Maternal smoking
Got a BRUE. What is the next step?
stratify in to high or low risk
Define a lower risk BRUE (4)
Pt older than 60 days (or 45 wks post conception for premie), first occurrence without multiple episodes, no CPR, no concerning findings on H and P
Suspected BRUE except the kid has a confirmed infection?
It’s an infection not a BRUE
What can be done to prevent SIDS (3)?
place on back for sleep, don’t share a bed, parental smoking cessation
When MUST you report child abuse?
Always - even if suspected, confirmation not needed
Name some child risk factors that may promote abuse (3)
premature birth, cognitive defect, physical disability
Name some care-giver risk factors that may promote abuse (4)
hx of being abused, young/single parent, non biologic care giver, poor
When is an abused child hospitalized (2)?
When injuries warrant admission or when no safe alternatives exist
Bilateral burns on the buttocks are?
dunk burns (kid picks up legs to escape hot water, buttocks hit first)
Bilateral burns to the feet to the ankles are?
Dunk burn
Child from an Asian family with circular burns on the back. They’re associated with?
Coining, NOT cigarettes, and should NOT be considered abuse
If you see small circular burns, suspect?
cigarette burns
What are some signs of abuse as the child interacts with the caregiver (3)
1) not crying around parents despite obviously painful injury; 2) running FROM caretaker; 3) comfort from health care workers
Failing to provide food, shelter, love, and nourishment to a child is classified as?
Neglect
Sexually transmitted infection in a child should prompt suspicion for?
sexual abuse
Non-purulent rhinorrhea, congestion, no cough, no fever: dx an tx?
Common cold - supportive care! (no abx!)
When do you get a CT scan for sinusitis?
Recurrent or refractory - looking for anatomic defects or foreign body
Antibiotic management for acute otitis media?
Amoxicillin first line, cephalosporin if pen allergic (cefdinir) without anaphylaxis, amoxicillin-clavulanate if recent abx use
Pain when pulling on the pinna, child swimmer. What is it and how to treat?
Otitis externa; tx with aural antibiotics (cipro) and aural steroids
Best diagnostic test for otitis media?
pneumatic insufflation
Strep pneumo, H flu, and Moraxela can cause which ENT infections?
Otitis media and sinusitis (differentiate by ear pain)
Catheter fails to pass through the nose of a young infant, dx?
Choanal atresia
Suspected pharyngitis in a 3 year old - first step?
rapid group A strep testing (Centor not helpful in preadolescent crowd)
Otitis media symptoms but there’s a bulge behind the ear + it’s rotated forward. Dx and tx?
mastoiditis - get a surgeon (and continue with abx)
Purulent rhinorrhea, fever, congestion, facial tenderness, greater than 10 days of symptoms: diagnosis and mgmt?
bacterial sinusitis. Amoxicillin-clavulanate 1st line, levofloxacin if pen allergic (it is atypical to use a fluoroquinolone in kids)
Childhood snoring, pink while crying, blue while feeding, dx?
choanal atresia
Pharyngitis + enlarged spleen = ? Do what?
Mono. Get a monospot test to confirm (EBV ELISA)
3 year old girl with anterior cervical nodes, no cough, tonsillar exudates, and a temp of 40C. Next step?
Rapid strep testing (Centor not helpful in preadolescent crowd)
Epistaxis doesn’t stop. Anterior bleed suspected. Tx?
cauterize anterior bleeds; pack posterior
What are the CENTOR criteria and how do they work
Cough (absent) + 1 Exudates +1 Nodes (adenopathy) +1 Temp gt 38C +1 OR: age lt 14 +1 OR age gt 44 -1 lt 1: supportive; 2-3: rapid strep (cx or tx); 4 or gt: tx as strep
Penicillin in group A strep prevents __ but not __.
rheumatic fever; post-strep glomerulonephritis
What is a sequelae of Measles?
subacute sclerosing panencephalitis
Dx if there are vesicles on an erythematous base across a single dermatome?
Shingles (varicella zoster)
Cough, coryza, conjunctivitis, koplik spots are symptoms of ?
Measles prodrome
What are vesicles on an erythematous base in various stages of healing indicative of?
Varicella (chicken pox)
Baby gets parvovirus B19; what are you worried about?
Aplastic anemia in baby (hemoglobinopathies); Hydrops fetalis in utero if mom is pregnant. Isolate mom
Vesicles on an erythematous base on hands, feet, and buccal mucosa - dx?
Hand-foot and mouth (coxsackie A)
What virus can cause bilateral facial swelling + orchitis?
Mumps
Separate measles from rubella clinically
Prodrome of cough, coryza, conjunctivitis, koplik spots (measles) vs generalized tender lymph nodes (rubella) - both have rash and fever (rubella has fever before rash, but not different enough)
What pathogen has a rash that starts on the face, spreads to the toes, then clears the same way?
Measles (and rubella?)
REALLY high fever, starts on trunk spreads outward - what’s the virus?
HHV-6 (roseola)
Empiric antibiotic therapy for meningitis in a 2 year old?
vancomycin + ceftriaxone
Empiric antibiotic therapy for meningitis in a baby less than 30 days old?
vanc + cefotaxime + ampicillin
Empiric antibiotic therapy for meningitis in a baby 30 days - 2 years?
vanc + cefotaxime
When can you trust an ELISA for HIV in a baby?
around 6 months when maternal antibodies have worn off
Pruritic rash in fingers, axilla, and multiple family members. Diagnosis and treatment?
scabies - permethrin (or lindane)
You see knits in hair, you think and treat with?
Lice, treat with permethrin
Itchy butt, positive tape test (there are worms) gets?
albendazole
Red hot tender joint in a child gets?
Arthrocentesis (the fact that its a child doesn’t change management)
PJP prophylaxis CD4 cutoff? Tx and alternate?
CD4 < 200; use TMP/SMX; Dapsone as alternative
Febrile infant with fussiness and bulging fontanelle. Diagnosis?
Meningitis
What is the FAILS criteria and how do you use it?
Focal neurologic deficit; Altered mental status; Immunocompromised; Lesions over the site of LP; Seizures
If any of FAILS is met, abx first, then CT, then LP
If NOT fails, LP first then abx
Treatment for primary apnea of newborn?
Stimulation with towels (rub back, tap feet)
What does APGAR stand for, and what is considered good?
Appearance, Pulse (gt 100), Grimace, Activity, Respiration; 7-10 is good
What do you do with a neonate who has hypoglycemia on its first check?
Give glucose - recheck; give IV if symptomatic (jitteriness, tremor, lethargy); feed if not symptomatic
What gets 0 points for each component of APGAR?
A: blue pale baby; P: pulse absent; G: grimace absent; A: activity absent; R: respirations absent
What gets 1 point for each component of APGAR?
A: Acrocyanosis; P: lt 100; G: with lots of tim; A: flexion; R: irregular
What gets 2 points for each component of APGAR?
A: pink; P: gt 100; G: with stim; A: resists extension; R: strong
What do you suction in a neonatal resuscitation and in what order?
Mouth then nose
What do you do if a neonate’s heart rate drops below 60 in the first ten minutes after birth (3)?
Positive pressure ventilation and CPR (3:1 with breaths), epinephrine via umbilical vein if not improving
Neonate in the delivery room with respiratory distress, hyper expanded lungs, and a “wet” chest XR. Dx and tx?
Transient tachypnea of the newborn. Treatment is oxygen (if needed) and occasionally CPAP
Neonate in the delivery room with respiratory distress, under expanded, and with atelectasis. Dx and tx?
Respiratory distress syndrome; may need surfactant and mechanical ventilation
Baby comes out of mom and isn’t breathing on its own. What’s that called?
Primary apnea
Bronchopulmonary dysplasia is caused by RDS due to decreased surfactant production. ___ is required for the diagnose. Xray shows __. How do you tx?
FiO2 required greater than 28 days; ground glass opacities; post birth tx with surfactant, pre birth give steroids to mom
Retinopathy of prematurity is caused by ___. It is worsened by __. How do you tx?
Oxygen toxicity (neoangiogenesis gone awry). increased FiO2 requirements; tx with laser
Intraventricular hemorrhage is seen in premies due to ___, which causes susceptibility to changes in blood pressure and therefore bleeds. How do you diagnose? Tx? What may result later on?
highly vascular ventricles; Cranial doppler (may see bulging fontanelles); Tx by decreasing ICP (shunts, drains); intellectual disability, seizures
Necrotizing enterocolitis is __. Seen in premies as __. Diagnose? Tx?
dead gut; bloody BM; XR (see pneumatosis intestinalis); NPO, IV abx, TPN (may need surgery)
What is mechanism of Hirschsprung’s?
Failure of neuron to migrate to distal colon
In Hirschsprung’s there is normal looking colon and dilated colon, which do you remove?
Normal looking colon (normal is bad - good colon should dilate)
If there is no anal opening on the first day of life…
imperforate anus: assess severity with cross table X-ray, consider VACTERL
What is VACTERL and how do you analyze each one?
Vertebra (U/S sacrum), Anus (xray), Cardiac (echo), TE fistula and Esophagel atresia (XR w/coiled tube), Renal (VCUG), Limb (XR) (things to rule out if there is no anal opening on the first day of life)
Treat a meconium ileus with?
Water-contrast enema
A diagnosis of meconium ileum means what other diagnosis?
Cystic fibrosis
Kids at risk for functional constipation?
school age or toilet age children
How does the dx of Hirschsprung differ in children and neonates (how it presents and what you do)?
Neonates: failure to pass meconium, contrast enema
Children: overflow incontinence or encopresis, anorectal manometry
You will still obtain rectal suction biopsy in both
Xray of Hirschsprung shows ___?
dilated proximal colon (normal colon) and normal looking distal colon (bad colon)
Tx when voluntary holding becomes involuntary constipation?
behavioral modification and bowel regimen
Explosive bowel movement on DRE in a child = ?
Hirschsprung’s (you are unblocking the obstruction)
Male baby, visible peristalsis, projectile vomiting, metabolic alkalosis - what’s the dx?
Pyloric stenosis
You diagnose pyloric stenosis, what do you do next?
assess for electrolyte abnormalities and fix those; then surgery to fix pylorus (pyloromyotomy)
Double-bubble sign and no distal air, polyhydramnios in utero - what’s the dx (2)?
Duodenal atresia or annular pancreas
Double bubble sign and normal gas patter beyond it; what’s the dx?
Malrotation
The pt obviously has pyloric stenosis. How do you make the diagnosis?
Donut sign on US (may also see olive shaped mass and visible peristaltic waves)
Multiple loops of bowel with air fluid levels - what’s the dx?
Intestinal atresia
Multiple loops of bowel with air fluid levels - how did that happen?
Mom did cocaine with baby in utero (vascular compromise) = intestinal atresia
The pt obviously has pyloric stenosis. What’s the next step?
BMP to look for (and correct) electrolyte abnormalities
What is an olive-shaped mass, visible peristalsis in a baby?
pyloric stenosis (also see non-bilious projectile vomiting)
Diagnose esophageal atresia with?
Xray with an NG tube in place - tube will be coiled
Baby has bubbling or gurgling with breathing, dx?
TE fistula
A baby looks to be yellow in the nursery - what’s the first step?
Check bilirubin - transcutaneous (sensor = screen) vs serum (diagnostic)
In the workup of a jaundiced neonate, what does a positive Coombs test mean?
Rh or ABO incompatibility
How do you diagnose biliary atresia?
US
If equivocal, HIDA scan after 1 wk of phenobarbital
Baby has an elevated unconjugated bilirubin at day 10 that wasn’t present at birth. Dx and tx? What is the cause?
breast milk jaundice - can temporarily interrupt breast feeding and supplement with formula or continue breast feeding - phototherapy if needed; Enzyme inhibition by mother’s milk causes insufficient conjugation
In the workup of a jaundiced neonate, what dose a high hemoglobin mean (2 causes)?
baby has too much blood - twin twin transfusion or delayed clamping of the cord
Persistent conjugated hyperbilirubinemia after aggressive measures to fix - what’s the dx?
biliary atresia
Baby has an elevated unconjugated bilirubin at day 4 that wasn’t present at birth. Dx and tx?
Breast feeding jaundice (not enough feeding, gut slows, increased bili reabsorption) - advice mom how to feed and how often
Kernicterus comes from which kind of bilirubin?
Unconjugated (lipid soluble so can cross BBB!)
How do you confirm an elevated transcutaneous bilirubin?
Get a serum bilirubin level
A mention of “black liver” in the vignette - what’s the dx?
Dubin-Johnson
Name 3 causes of increased conjugated bilirubinemia in a neonate
1) biliary atresia; 2) sepsis; 3) metabolic (Rotor, Dubin Johnson)
Name 4 causes of increased unconjugated bilirubinemia in a neonate
1) hemolysis (G6PD, pyruvate kinase defic, sickle cell); 2) hemorrhage (cephalo-hematoma); 3) Transfusion (twin-twin or delayed cord clamping); 4) Reabsorption (breast feeding vs breast milk jaundice)
Name 4 findings due to maternal estrogen effects in newborns
1) breast hypertrophy (boys and girls); 2) swollen labia; 3) physiologic leukorrhea (whitish vaginal discharge); 4) uterine withdrawal bleeding
Bilious vomiting in vignette, a double-bubble with multiple air fluid levels on XR image
Intestinal atresia
If you find imperforate anus in a newborn, what do you do next?
Up-side-down baby gram (Xray)
Coiled NG tube in an esophagus in a newborn?
Esophageal atresia (look for VACTERL)
Intestines are out of baby, in the midline, and are contained in sac. What is the dx and what do you do next?
Omphalocele; give a silo
Intestines are out of baby, they are to the right of midline and have no membrane. What is the dx and what do you do next?
Gastroschisis; give a silo
Premature neonate develops bloody diarrhea, what’s the dx? Next step?
Necrotizing enterocolitis; get an XR
Scaphoid abdomen and bowel sounds in the chest in a newborn, what’s the dx? Next step?
Diaphragmatic hernia; XR
How do you treat congenital diaphragmatic hernia?
give pulmonary surfactant and surgical repair
Failure to pass meconium, XR shows dilated proximal colon and distal normal colon. What’s the dx and how do you treat it?
Hirschsprung’s; remove the normal looking colon
Biliary atresia presents with persistent or worsening jaundice at what age? How do you diagnose it?
2 weeks; US shows absence of ducts and HIDA scan after phenobarbital shows no contrast in GI
Neural tube defects are caused by what (2)? What would you see in prenatal screen (2)?
Folate deficiency and genetic syndromes; visible on US in utero and positive AFP screen
Myelomeningocele is associated with ___.
chiari type II
Cleft lip/palate can be caused by failure of __ or __.
growth or fusion of underlying structures
Floaties aren’t sufficient for pool safety; why?
they hold up arms, not the head (child can still drown)
Football player gets knocked out after a big tackle but remembers everything, what does he have?
Concussion
How do you prevent drowning in pools?
supervision, life jackets
A teen is involved in a MVA, isn’t wearing his seatbelt, flies through the windshield and suffers LOC with a single lucid interval then LOC. Test and suspicion of dx?
CT scan; epidural hematoma
A three year old comes in with bruises form her toes to knees, dx?
Abuse
Football player takes a big hit, wobbles, comes out, but quickly shakes it off and appears ok. Next step and why?
Don’t allow return to play - 1) cognitive deficits may not show up immediately; 2) higher incidence of second impact syndrome
What is the most effective way to prevent trauma from guns?
Eliminate them from the home
What are the 4 criteria for deciding mild vs severe concussion? What do you do if it is mild vs severe?
FND (none vs positive); LOC (lt vs gt 60 seconds); Headache (none/improving vs present/worsening); Amnesia (none vs retrograde/anterograde);
For mild no CT, d/c home; for severe CT scan to r/o bleed and observe. Both step wise return to play
What is the parkland formula for pediatric burns and how do you calculate %BSA?
%BSA x Kg x 4 (2nd and 3rd degree burns only) Head: 9+9 = 18 Front thorax is 9+9 = 18 Back thorax is 9+9 = 18 Arms are left = 9 and right = 9 = 18 Legs are 9+9+9 = 27
Timing of fluids in burn patients?
50% of fluid in 8hrs and the second 50% of fluid in the next 16
Concussion symptoms (4)?
- Physical (photophobia, nausea, headache)
- cognitive (memory issues)
- emotional (moody, depression)
- sleep problems
Infant is in a coma, subdural on CT, dx?
shaken baby syndrome, abuse
Rear facing car seat for baby until what age?
2 years old
Kids need a booster seat until?
4’9”, 8-12 years old
Bee sting with a red wheal around the site. What do you do?
Supportive care. You can use antihistamines
Young child develops an itchy rash on their face, what’s the first thing to do?
Evaluate/withdraw recently added foods to diet
Vomiting, bloody diarrhea, failure to thrive in infant on formula - dx and tx?
milk-soy protein allergy; switch to hydrolyzed formula
A child has rhinorrhea and allergic shiners. How do you evaluate?
Take history for triggers and remove them (no skin testing or RAST)
What’s the first line treatment for seasonal allergies?
H1 blockers (loratidine = fexofenadine = cetirizine)
Bee sting with red wheals, hypotension, and wheezing. What is the immediate treatment?
IM Epi 1:1000
When should you do skin testing for allergies?
In the case of severe or refractory disease
What can you tell mom and dad about allergens when it comes to household safety for baby?
Remove carpets, clean regularly (dust mites), and stop smoking
Name the findings associated with allergic rhinitis in children (6)
Allergic shiners, allergic salute, pale mucosa, boggy mucosa, polyps, cobblestoning
What is the best tx (after avoiding triggers) for allergic rhinitis?
Intra nasal steroids!! (anti-histamines are not as good!)
A child has ADHD but the question is about seizures - dx? Tx?
Absence; Ethosuximide (valproate as back up)
What makes a febrile seizure complex (3)? Why does it matter?
complex if: 1) not generalized, 2) gt 15 mins, 3) multiple episodes in 24hrs. Simple seizures do not require any additional workup
What do you NEVER give to a febrile seizure? What do you give to tx it?
Aspirin (reyes syndrome); tx underlying cause (acetaminophen does not tx or prevent recurrence of febrile seizures)
Less than 6 months old, bilateral jerking of head and extremeties - dx? How do you treat? What is seen on interictal EEG?
Infantile spasms (West syndrome); ACTH; hypsarrhythmia
Seizure, ash leaf spot on wood’s lamp - dx? What’s the next step?
Tuberous sclerosis; CT head or MRI brain (looking for brain tubers)
When do you use bentos to treat a febrile seizure?
ANY seizure lasting more than 5 minutes (abortive bentos)
What do you do about an anal fissure in a child?
Treat constipation if present; check for IBD if older child
You’re worried about a GI bleed in a premature neonate - what do you get? What would you see on X-ray?
Xray for necrotizing enterocolitis; pneumatosis intestinalis (air in the wall of the bowel)
Currant jelly diarrhea in a child, pain relieved by knee to chest position. What’s the dx?
Intussusception
Sausage shaped mass and currant jelly diarrhea - dx?
Intussusception
What are the 3 other things you should look for in a pt with necrotizing enterocolitis?
1) intraventricular hemorrhage (US w/doppler); 2) retinopathy of prematurity (optho exam); 3) Bronchopulmonary dysplasia
What test do you do to investigate intussusception?
Air enema (best test and often curative); can also do X-ray (to look for perf or obstruction) and US which would show target sign (aka donut)
What is the tx for intussusception? What is the back up and when do you do it?
Air enema (surgery if that doesn’t work or if pt has peritonitis, perforation)
Diagnostic step for a meckel’s diverticulum?
Technetium-99 scan
What do you get if you’re worried about a GI bleed in a healthy term neonate right after delivery?
Apt test (differentiates fetal from maternal blood - aka alkali test) - baby might have swallowed mom’s blood
Warm upper extremities, cool lower extremities in a child, what’s the diagnosis?
Coarctation of the aorta
You want to keep the patent ductus arteriosus open, what do you give? What do you give to close it?
Prostaglandin; indomethacin (anti-prostaglandin)
Fixed split at S2?
Atrial septal defect
What are indications to surgically repair a VSD (4)?
right sided hypertrophy, increased R sided pressures, failure to thrive, and heart failure (amongst others)
Holosystolic murmur in a neonate - what’s the dx? What’s the dx in an adult?
VSD; mitral regurg
Cyanotic congenital heart disease at age 3 - what’s the diagnosis?
Tetralogy (all others are immediate at birth)
Mom has diabetes and the question asks about congenital heart disease
Transposition of the great vessels (not gestational diabetes!)
Down syndrome baby and a question about congenital heart disease = ?
atrioventricular septal defect
In most cases how do you diagnose a congenital heart disease?
Echo
Name 3 associations with VSD, 1 with ASD, and 1 with AV septal defect
VSD: Fetal Alcohol Syndrome, Downs, VACTERL
ASD: Downs
AV Septal Defect: Downs
Name 1 association each with PDA, coarctation, transposition of the great vessels, tetralogy of fallot, and truncus arteriosus.
PDA: Congenital Rubella Coarctation: Turners Transposition: Maternal Diabetes Tetralogy: DiGeorge Truncus: DiGeorge
Children with tetralogy of fallot can relieve their cyanosis by ___. How does this work?
squatting (tet spells) - this increases both venous return and systemic vascular resistance, forcing blood in to the pulmonary artery instead of the aorta
Sandpaper rash in a child with fever?
Scarlet fever (also will see pharyngitis, tonsillar erythema & exudates, strawberry tongue, tender anterior cervical nodes)
Legg-Calve-Perthes disease is idiopathic __ of the __. Classically presents in young children (age __ to __) with progressive __ and/or a __. Physical exam shows these two findings.
osteonecrosis; femoral epiphysis; 3-12 (peak 5-7); leg pain; limp; 1) decreased hip range of motion; 2) thigh muscle atrophy
(XR shows flattened and fragmented femoral head)
What is the most common heart defect with Down syndrome?
Complete atrioventricular septal defect
Name 3 features of leukocyte adhesion deficiency
1) recurrent skin and mucosal bacterial infxns (omphalitis, periodontitis) (no pus, poor wound healing); 2) delayed umbilical cord separation (gt 21 days); 3) marked peripheral leukocytosis with neutrophilia
Fracture in kids that DOES NOT involve the growth plate and is closed. What’s the next step? What if it does involve the growth plate?
Cast; Open reduction and internal fixation (ORIF)
Teenage athlete, knee pain, nodule on the tibia, diagnosis?
Osgood-Schlatter
Clicky hip in a newborn in the newborn nursery - dx? What do you do next?
Potential developmental dysplasia of the hip - reassess in 4 wks, and if still there US to confirm, then harness
Obese teenager with non traumatic hip pain. Test and diagnosis?
Xray - slipped capital femoral epiphysis
How do you make the diagnosis of scoliosis?
Adam’s test (have the child lean forward and see asymmetry)
Describe the XR pattern of osteogenic sarcoma?
Sunburst pattern in distal bone (often femur)
6 year old child with an insidious onset antalgic gait - dx?
Legg-Calve-Perthes disease (avascular necrosis) - antalgic = abnormal gait to help avoid pain
A girl has retinoblastoma at birth; what cancer should be monitored for?
Osteosarcoma
A young kid with fever and pain of any joint - most serious diagnosis?
Septic arthritis
Hip pain in a child after a viral illness - dx?
Transient synovitis - can be confused for septic arthritis (may need arthocentesis to rule out)
What diagnostic test do you do for slipped capital femoral epiphysis?
Frog-leg Xray (XR “plain film” isn’t enough)
Fever, swelling, joint pain in a teen - next step?
Arthrocentesis (fever + joint swelling = tap)
What is the translocation in Ewing’s sarcoma? What is the pattern on XR?
t(11:12); onion skin patter on mid shaft
What’s the one thing you’ll check for in a long bone fracture in a child?
Growth plate involvement (if positive, go straight to surgery)
What are the 4 Kocher criteria and what are they used for?
Used to detect septic arthritis: +1 for any positives
non-weight bearing, temp gt 38.5/101.3, ESR gt 40, WBC gt 12
Other than involving the growth plate, name 4 other considerations for pediatric bone fractures that would make you choose ORIF.
Comminuted (fracture in which the bone has broken into several pieces), angular, displaced, open
How do you definitively diagnosis a child with sickle cell disease?
Hemoglobin electrophoresis
How do you treat iron overload in sickle cell disease?
Deferoxamine
What’s the genetic problem in sickle cell disease?
Valine for glutamine in the 6th position on the beta global gene cluster on chromosome 11
What medication can help prevent sickle pain crises? How does it work?
Hydroxyurea; increased HgbF (which can’t sickle); hydration also helps!
How do you treat an acute vaso-occlusive crisis?
IVFs, oxygen, and pain control (abx if suspect an infxn)
If there is acute chest, what is the treatment? Name 2 other conditions that require the same tx.
Exchange transfusion; priapism, stroke
Inability to ambulate, hip pain, and in sickle cell pt. What is the diagnosis and diagnostic step?
Avascular necrosis of the hip, take an XR
Kids with sickle cell auto infarct their spleens - what do you do for them?
Vaccinate against encapsulated organisms and give prophylactic penicillin until age 5
How can you tell if someone is in a sickle cell crisis (3)?
Sickled cells on smear, bili is up from baseline, reticulocytes are up from baseline
If you see salmonella osteomyelitis, what disease should you think of?
sickle cell
What type of anemia are kids with sickle cell likely to get if they aren’t cared for?
Folate deficiency (they are actually at risk of iron overload because of transfusions)
Treat avascular necrosis in a newly diagnosed pt with?
NSAIDs and rest (casting and surgery are also options but will vary based on severity)
The most common cause of osteomyelitis in pts with sickle cell?
Staph aureus (NOT salmonella - though if you have salmonella osteo you likely have sickle cell)
Name 4 B cell immunodeficiencies and 1 T cell.
1) Bruton’s X-linked agammaglobulinemia
2) Common variable immunodeficiency
3) IgA deficiency
4) Hyper IgM
1) DiGeorge
Name 3 Phagocyte immunodeficiencies
1) Leukocyte adhesion deficiency
2) Chronic granulomatous disease
3) Chediak Higashi
Name 3 combined immunodeficiencies
1) Wiskott-Aldrich (xlinked)
2) Ataxia telangiectasia
3) Severe combined immunodeficiency (SCID)
Which set of immunodeficiencies all have normal CBCs?
B-cell deficiencies
Small chin, small mouth, low-set ears, wide spaced eyes, and ___. What’s the diagnosis?
absent thymic shadow; DiGeorge
Anaphylactic reaction to a blood transfusion - dx?
IgA deficiency
When does X linked agammaglobulinemia usually appear and when does common variable immunodeficiency? How do you treat both?
6 months; late childhood or early teens
(CVID is less severe - missing about 2 out of 3 Ig’s (A, G, M) instead of all); with both you can give scheduled IgG but to cure they need BM transplant
Boys with lots of recurrent infection btwn ages 1-2, dx?
Bruton’s X-linked agammaglobulinemia
What is the diagnosis if you see low IgA, low IgG, and high IgM?
hyper IgM syndrome
Boys, eczema, thrombocytopenia with infections. What’s the diagnosis?
Wiskott-Aldrich (problem with antigen presentation)
What will an immunoglobulin panel look like in Brutons?
All down - low IgA, IgG, IgM, IgE
Recurrent Neisseria infections, what’s the diagnosis?
terminal complement deficiency C5-C9 Mac attack
What’s a cause for severe combined immunodeficiency?
adenosine deaminase deficiency (causes an autosomal recessive pattern)
How do you confirm an XLA diagnosis?
Type the BTK gene
Delayed separation of cord, dx? Name another symptom
Leukocyte adhesion deficiency; toxic but no pus! (WBCs can’t leave blood)
Recurrent staph abscesses are seen in what immunodeficiency? How do you diagnose?
chronic granulomatous disease (no respiratory burst - will eat bugs but cannot kill catalase + organisms); Nitro blue test will fail to turn blue
Disruption of complement pathway that causes angioedema but not associated with immunodeficiency - dx?
C1 esterase deficiency
Obviously syndromic physical appearance and immunodeficiency - dx? How do you treat these pts (3)? What else should you look out for in these pts.
DiGeorge syndrome; TMP-SMX ppx, IVIg bridge to thymic transplant; decreased calcium 2/2 PTH deficiency (3rd pharyngeal pouch absent)
Severe immunodeficiency involving both T and B cells. Abscesses and mucosal infxns - dx? How do you treat (3)?
SCID; TMP-SMX against PCP, isolate!, BM transplant is curative (no risk of GVHD)
Name 3 conditions that qualify you to receive palivizumab for RSV prevention
1) preterm birth (lt 29 wks gestation); 2) chronic lung disease of prematurity; 3) hemodynamically significant congenital heart disease
Name 3 clinical manifestations of Kartagener’s (primary ciliary dyskinesia)
1) recurrent sinopulmonary infxns and 2) bronchiectasis - both due to immotile cilia leading to poor mucociliary clearance; 3) +/- situs inversus (Kartagener’s!)
Name 4 clinical manifestations of HSP (Henoch-Schonlein purpura). How do you tx?
1) palpable purpura; 2) arthritis/arthralgia; 3) abdominal pain, intussusception; 4) renal disease similar to IgA nephropathy; supportive tx (hydration and NSAIDs) - in severe cases can hospitalize and give systemic glucocorticoids
The most common predisposing factor for acute bacterial sinusitis is ____.
a viral URI
Mucopurulent discharge from one eye 5-14 days into life - dx? Tx? What would the gram stain show?
Chlamydia; erythromycin PO; nothing
Purulent disharge, bilateral, 2-7 days into life - what would the gram stain show? Tx?
gram negative diplococci (gonorrhea) - ceftriaxone IM
Unilateral mucopurlent discharge from one eye 5-14 days into life - what should you have used for ppx?
Nothing (there is no ppx for baby against chlamydia)
Red light reflex shows a bright white thing, dx? Tx?
Retinoblastoma; surgery (NEVER radiation)
What do you do about congenital cataracts? What are they usually caused by?
Remove them before amblyopia sets in; TORCH infections
Purulent disharge, bilateral, 2-7 days into life - what should you have used for ppx?
Topical erythromycin
A baby with cataracts not present at birth is likely caused by?
Galactosemia
In retinopathy of prematurity how do you diagnose and tx?
Diagnose with optho exam showing growth on retina; laser ablation
If baby has retinopathy of prematurity, name 3 other conditions you should consider
1) necrotizing enterocolitis; 2) bronchopulmonary dysplasia; 3) intraventricular hemorrhage
What is the one thing you NEVER do with hypo or epispadias?
Circumcision - use the foreskin to reconstruct the penis
Intense colicky pain after a teenager first experiments with alcohol, what’s the dx?
Ureteropelvic junction obstruction (works at normal urinary flow - problems at increased flow)
You want to dx vesicoureteral reflux - what test do you get?
voiding cystourethrogram (VCUG)
Any UTI in an infant should prompt investigation for what? How do you check it?
vesicoureteral reflux; first U/S, the VCUG if abnormal
You want the confirmative diagnostic step of a bladder mass, what test do you get?
cystoscopy
A testicle could not be palpated, what do you do (plan out the boys life)
Give it a year (6 mo?) to descend on its own, then bring it down yourself. Take it out after puberty
Dysmorphic red blood cells in a child with microscopic hematuria. What is the general name for this condition?
Glomerulonephritis
A girl who is able to void, is toilet trained, but leaks constantly anyway - dx? Tx?
Ectopic ureter (aka low implantation of the ureter); reimplant
You’re thinking hydronephrosis or hydroureter, what test do you get?
U/S
Oligohydramnios in male infant, no urine output on first day of life with palpable bladder. Dx? Tx?
Posterior urethral valves; catheter to relieve obstruction and surgery to resolve problem
In a pt with posterior urethral valves, what would you see on ultrasound?
Hydronephrosis
Hearing loss, ocular abnormalities, and renal disease - dx? pathogenesis?
Alport syndrome; basement membrane thinning (and splitting) due to abnormality of type IV collagen (hereditary nephritis)
In lead chelation, ___ is typically used when lead levels are 45-69. __ plus __ is used on an emergency basis for levels greater than 70 or acute encephalitis
Dimercaptosuccinc acid (DMSA, Succimer); Dimercaprol (british anti-lewisite) plus calcium disodium edetate (EDTA)
Name 5 clinical features of DiGeorge syndrome (pneumonic!)
CATCH: Conotruncal cardiac defects (truncus arteriosus, tetrology of Fallot, interrupted aortic arch, septal defects); Abnormal facies; Thymic aplasia/hypoplasia; Cleft palate; Hypocalcemia
Name 3 clinical features of McCune-Albright syndrome
1) peripheral precocious puberty; 2) irregular cafe-au-lait macules; 3) polyostotic fibrous dysplasia (recurrent fractures)
(caused by mutation in GNAS gene leading to over production of pituitary hormones)
What is the most common cause of pediatric stroke
Sickle cell disease
___ is a macrocytic pure red aplasia associated with several congenital anomalies such as short stature, webbed neck, cleft lip, shielded chest, and triphalangeal thumbs
Diamond-Blackfan syndrome (DBS)
A child has many outbursts in class, is started on stimulants for ADHD, the outbursts get worse - dx? Tx?
Tic disorder; dopamine antagonists (fluphenazine, tetrabenazine)
A child misbehaves at school, appears easily distracted. They’re able to sit quietly at home and watch TV - dx?
Troublemaker (not ADHD)
Tx: child is fidgety, interrupts theres, is easily distracted, has poor grades, and can’t follow instructions at home
Stimulant med (methylphenidate)
Child has impaired speech, poor social function, repetitive behaviors, and rocks back and forth - dx?
Autism spectrum disorder
Child acquired risk factors for intellectual disability disorders (3)
lead poisoning, trauma, cerebral palsy
Maternal acquired risk factors for child’s intellectual disability
Hypothyroid while pregnant, alcohol while pregnant
How do you grade an intellectual disability?
Based on their adaptive functioning (aka ability to take care of themselves/socialize) - NOT IQ
What does an IQ less than 70 mean?
Person is 3 SDs below the mean
A 6 month old girl has normal developmental progress, but then regresses - dx?
Rett syndrome
What are the two main symptoms of Autism spectrum disorder?
Impaired social communication and Repetitive behaviors
Chromosomal causes of intellectual disability (3)
Down syndrome, Fragile X, Cri-Du-Chat
Lying, cheating, hurts animals, less than 18 yo, dx?
Conduct disorder
Child yells, talks back to teachers and parents, but isn’t aggressive with peers or animals - dx?
Oppositional defiant disorder
Older than 7 yo, still bed wetting, frequently cries from embarrassment - tx (5)?
Positive reinforcement, alarm blankets, water restriction; medication tx = DDAVP, TCAs are okay
Kawasaki disease (aka mucocutaneous lymph node syndrome) is a vasculitis characterized by fever greater than ___ days in addition to gt/= 4 of these 5 findings
5 days; 1) conjunctivitis (nonexudative); 2) oral mucosal changes (strawberry tongue, fissured lips); 3) Rash; 4) extremity changes (desquamation of hands and feet); 5) cervical lymphadenopathy (gt 1.5 cm node)
How do you treat Kawasaki?
IVIg and aspirin!
The first step in the evaluation of primary amenorrhea is ___ to determine __.
pelvic exam; whether the ovaries, uterus, and vagina are present or absent. Ultrasound is the preferred imaging modality
___ is increased laxity of supraglottic structures, which presents as __ that worsens when __. How do you diagnose? What is the peak age?
Laryngomalacia; inspiratory stridor; supine; Clinical dx or flexible laryngoscopy; 4-8 months
Newborn with bilious emesis - next 4 steps?
stop enteral feeds, NG tube decompression, IV fluids, abdominal Xray (to rule out pneumoperitoneum from intestinal perf)
Name 4 causes of bilious emesis
1) meconium ileus (CF); 2) Hirschsprung disease; 3) Malrotation (volvulus); 4) Duodenal atresia
Newborn with bilious emesis, X-ray shows dilated loops of bowel - what’s the next test to determine cause
contrast enema - will either show microcolon (meconium ileus = CF) or rectosigmoid transition zone (Hirschsprung)
Diagnosis of ___ can be confirmed with eosin-5-maleimide binding test and ___ test.
Hereditary spherocytosis; acidified glycerol lysis test
look for triad of combo’s negative hemolytic anemia, jaundice, splenomegaly - and of course spherocytes
Causes of meningitis in children less than 3 months of age (4); 3 months - 10 years (2); greater than 11 years (1)
Group B strep, E coli (and other gram negs), Listeria, Herpes; Neisseria meningitidis and strep pneumo; N meningitidis
Painless hematochezia in a young toddler is most likely due to __. Diagnosis is confirmed with __.
Meckel’s diverticulum (if it has ectopic gastric tissue, it secretes HCl, causing mucosal ulceration of surrounding small bowel); technetium-99m pertechnetate scanning
Septic arthritis in birth-3months: what organisms (3) and what abx (2/3)
staphylococcus, group B strep and gram neg bacilli; antistaph agent (nafcillin or vancomycin) PLUS gentamicin or cefotaxime
Septic arthritis in pt older than 3 months: what organisms (3) and what abx (4)
staph, group A strep, and strep pneumoniae; nafcillin, clindamycin, cefazolin, or vancomycin
Patient has channel atresia - may be isolated or part of this syndrome (name the 6 parts)
CHARGE syndrome: Coloboma, Heart defects, Atresia choanae, Retardation of growth/development, Genito-urinary anomalies, Ear abnormalities/deafness
___ is characterized by macrosomia, macroglossia, umbilical hernia/omphalocele, hemihyperplasia, and hypoglycemia. Children must be closely monitored for development of these two tumors
Beckwith-Wiedmann syndrome; Wilms tumor or hepatoblastoma
In pts with primary amenorrhea with confirmed uterus present, the next step is to order ___. If it is increased, do ___. If it is decreased, do __.
FSH; karyotyping (peripheral origin); pituitary MRI (look for a lesion in the sella turcica)
Pt with combination of neurologic (ataxia, dysarthria), skeletal (scoliosis, feet deformities), and cardiac (concentric hypertrophic cardiomyopathy) manifestations has __.
Friedreich ataxia (most common type of spinocerebellar ataxias)
