Pediatrics Flashcards
1
Q
child < 5 gets sick a week before (not always) patient appears well then has enlarged, erythematous, tender, cervical node possible abscess formation
A
Acute Unilateral Cervical Lymphadenitis
most commonly due to staph or strep
anaerobes associated with periodontal disease (poor dental hygiene)
use antibiotic therapy (clindamycin or amoxicillin-clavulanate)
do incision and drainage if abscess present
2
Q
complications of bronchiolitis
A
apnea (especially infants age < 2 months)
respiratory failure
3
Q
diagnostic criteria for acute bacterial rhinosinusitis
A
- persistent 10 or more days without improvement
- severe onset (fever > 39C or 102.2F + drainage) more than 3 days
- worsening symptoms following initial improvement
- need 1/3
- give amoxicillin + clavulanate
4
Q
what do you give to a premature baby that is exclusively breast fed
A
IRON AND VITAMIN D
- preterm infants are at higher risk of iron deficiency so they should be on iron up till age 1
- all exclusively breast fed babies get vitamin D supplementation
*full term babies have enough iron for the first 4-6 months of life
5
Q
management of a baby with hypospadias
A
defer circumcision
urologic evaluation for surgical repair
possible karyotype analysis, get pelvic ultrasound if severe
6
Q
thyroglossal duct cyst vs pharyngeal cleft cyst
A
TDC –> anterior midline mass that moves with swallowing, embryologic anomaly made up of normal thyroid tissue
can present after URI
confirm presence of normal thyroid tissue then surgically resect the cyst , associated tract, and central portion of the hyoid bone
PCC –> lateral neck mass due to persistent cervical sinus that does not move with swallowing
7
Q
how does cervical reactive lymphadenopathy present
A
enlarged neck mass after URI
lateral
involves multiple nodes
does not move with swallowing
8
Q
kid has down syndrome and no meconium.. what do you think
A
hirschsprung
9
Q
kid has CF and no meconium.. what do you think
A
meconium ileus
10
Q
management of neonatal clavicular fracture
A
usually gets better within 7-10 days so do nothing but be gentle with them
you can also staple their shirt to the their sleeve so they dont move their arm for further damage
11
Q
patient with very low fever or no fever with some hip pain and difficulty walking but can bear weight on it and was sick with a viral illness but has all normal labs
A
transient synovitis
full recovery within 1-4 weeks
conservative management with NSAIDs
12
Q
how to treat patients and their families if someone has pertussis
A
its so contagious that you freaking treat them allllll with macrolides REGARDLESS OF VACCINATION STATUS
13
Q
kid with purple “bruises” on his legs, arthritis/arthralgias, abdominal pain, and blood in urine
A
henoch-schonlein purpura
- IgA mediated vasculitis
- they are purpura not bruises
- abdominal pain, intussusception
- renal disease (hematuria- most common)
- symptoms often preceded by mild URI
supportive therapy (hydration and NSAIDs) hospitalization and systemic glucocorticoids in pts with severe symptoms
14
Q
migratory arthralgias and no gram stain or culture found/grown
A
borrelia burgdorferi
15
Q
decreased B cells due to absent T cells
A
severe combined immunodeficiency
16
Q
common variable immunodeficiency
A
defect in B cell differentiation
decrease in plasma cells and immunoglobulins
17
Q
most common cause of a child with back pain that has pain with extension and rotation but not flexion
A
spondylolisthesis
-fracture of pars interarticularis then usually pinches L5
18
Q
risk factors for hypertrophic pyloric stenosis
A
first born boy
erythromycin
bottle feeding
*you will see an olive shaped abdominal mass
19
Q
acute rheumatic fever
A
JONES criteria Joints O = shape of heart Nodules (subcutaneous) Erythemia marginatum Sydenham chorea
*give penicillin for group A strep
20
Q
baby with pale stools and hepatomegaly
A
biliary atresia
*most common indication for peds liver transplant
21
Q
transient tachypnea of newborn vs. respiratory distress syndrome
A
TTN –> tachypnea begins shortly after birth and resolves by day 2 due to inadequate alveolar fluid clearance at birth resulting in mild pulmonary edema, bilateral perihilar linear streaking … usually in term baby born via c-section
RDS –> premature infant with grunting, flaring, and retractions immediately after birth due to surfactant deficiency resulting in alveolar collapse and diffuse atelectasis, ground glass appearance on x-ray with granularities
*treat with continuous positive pressure ventilation
22
Q
anaphylaxis
A
severe allergic reaction with HYPOTENSION or symptoms involving > 2 organ systems after exposure to allergen
*treat with IM epinephrine
23
Q
what do patients have in turner syndrome (XO)
A
short, wide chest, webbed neck, narrow/high arched palate, coarctation of aorta (diff bp in upper vs lower extremities), bicuspid aortic valve, horseshoe kidney, and streak ovaries/amenorrhea/infertility
pts are at increased risk of osteoporotic fractures due to estrogen deficiency from ovarian dysgenesis
*more than 50% of these pts also have congenital lymphedema due to lymph network dysgenesis, presents as nonpitting carpal and pedal edema
24
Q
what does organophosphate poisoning look like
A
acetacholinesterase inhibitors
Muscarinic: Diarrhea /diaphoresis Urination Miosis Bronchospasms, bronchorrhea, bradycardia Emesis Lacrimation Salivation
Nicotinic: muscle weakness, paralysis, fasciculations
25
vagina ends in blind pouch and kid has no uterus or ovaries but has bilateral abdominal masses
androgen insensitivity (XY)
26
clinical features of sturge-weber syndrome
port wine stain (trigeminal nerve distribution V1/2)
leptomeningeal capillary-venous malformation
seizures (possibly with hemiparesis)
intellectual disability
visual field defects
glaucoma
dx via MRI of brain with contrast
treat with laser therapy, antiepileptic drugs, intraocular pressure reduction
27
acute chest syndrome
pulmonary vasoconstriction or infection
| pt presents with fever, chest pain, new infiltrate on chest radiograph
28
what to think about in pts with acute severe anemia in sickle cell patients
1. aplastic crisis (decreased reticulocytes)
- transient arrest of erythropoiesis
- secondary to infection (parvo B19)
2. splenic sequestration crisis (increased reticulocytes and decreased platelets)
- splenic vaso-occlusive --> rapidly enlarging spleen
- occurs in children prior to autosplenectomy
29
patient with hemophilia A or B will have what joint findings
hemosiderin deposition and fibrosis
-they can develop hemophilic arthropathy from recurrent hemarthroses associated with hemosiderin deposition leading to synovitis and fibrosis within the joint
*treat by replacing factor and possibly adding desmopressin
30
baby with empty/hypoplastic/poorly rugated scrotum or hemiscrotum with or without inguinal fulness presenting with fussiness and in a lot of abdominal pain
baby has cryptorchidism (testicle is in abdomen and has torsion)
risk factors --> prematurity, small for gestational age, low birth weight, genetic disorders
treatment --> orchioplexy before age 1
complications --> inguinal hernia, testicular torsion, subfertility, testicular cancer
31
most common carrier of rhabdovirus in USA
bats (causes rabies)
| -ascending flaccid paralysis plus all the typical symptoms
32
3 most common pathogens causing acute otitis media AND bacterial rhinosinusitis
1. strep pneumo
2. H. influenza (most common for rhino is nontypeable)
3. moraxella catarrhalis
33
patients with chronic granulomatous disease have increased risk of what and why
staph aureus, serratia, and fungi
they get lots of recurring abscesses
NADPH oxidase abnormalities causing decreased superoxide production
34
atlantoaxial instability
- seen in > 10% pts with down syndrome
- excessive laxity in posterior transverse ligament increases laxity b/w C1 and C2
- symptoms can develop due to compression of spinal cord
- upper motor neuron findings, urinary/fecal incontinence, gait changes, and weakness
35
serum sickness-like reaction
immune complex formation due to abx reaction or acute hepatitis B
- symptoms: 1-2 weeks post exposure, fever, skin rash, polyarthralgia
- treatment: remove/avoid offending agent, supportive care, steroids or plasmaphersis if severe
36
lyme disease prevention.. when do you do this
single dose doxycycline IF (must have all 5)
1. ixodes tick identified
2. tick attached for > 36hrs hours or engorged
3. prophylaxis started within 72hrs of tick removal
4. local borrelia burgdorferi infection rate > 20% (ex: New England)
5. No contraindications to doxycycline (ex: pregnancy)
37
what is the first thing to do when a kid swallows something incorrectly
clothing removal
38
pathology of coarctation of a aorta
thickening of tunica media of aortic arch near the ductus arteriosus
39
what is the most common inherited form of intellectual disability
x-linked CGG trinucleotide repeat --> Fragile X (hypermethylation at FMR1 gene)
40
beckwith-wiedemann syndrome
deregulation of imprinted gene expression in chromosome 11p15
- fetal macrosomia, rapid growth until late childhood
- omphalocele or umbilical hernia
- macroglossia
- hemihyperplasia
- complications: wilms tumor and hepatoblastoma
- surveillance: serum a-fetoprotein, abdominal/renal ultrasound
41
evaluation of primary amenorrhea (absence of menarche by 15 years old)
do pelvic ultrasound first to check for uterus
if present --> check serum FSH
if absent --> karyotype serum testosterone
42
alport syndrome
X-linked mutation of type 4 collagen
nephropathy --> hematuria, progressive renal insufficiency (proteinuria and hypertension), bilateral sensorineural hearing loss, anterior lenticonus/lens protrusion
dx --> molecular genetic testing, renal biopsy showing longitudinal splitting of GBM
43
baby comes in with cyanosis
pulse oximetry saturation ~85%
dark chocolate colored blood
methemoglobinemia
history --> exposure to oxidizing substances (dapsone, nitrates, local/topical anesthetic)
-saturation gap >5% difference between oxygen saturation on pulse oximetry & ABG
-normal PaO2
-give pt methylene blue
44
complications of drowning
all of these are as a result of hypoxemia from fluid aspiration (aspirated liquid washes out alveolar surfactant) causing...
- pulmonary edema
- respiratory insufficiency
- ARDS
45
anterolateral and superior displacement of the proximal femur along the along the physis (growth plate) in either super obese or super tall kid
slipped capital femoral epiphysis
46
immune thrombocytopenia
IgG antibodies form against platelets and try to kill them all... can be triggered by illness
- usually resolves in 3 months
- chronic is < 100,000 platelets for > 1 year
treat with IVIG, glucocorticoids or splenectomy if super bad but if the patient has no bleeding and looks fine then just observe
47
first line treatment for pts with sickle cell and many acute pain crises
hydroxyurea which may cause myelosuppression
48
HPV vaccine
under 15 --> two shots 6 months apart
| 15 and over --> 3 shots
49
criteria for systemic juvenile idiopathic arthritis
```
fever > 2 weeks
arthritis > 6 weeks
pink macular rash that worsens during fever
leukocytosis, thrombocytosis
elevated inflammatory markers
anemia
```
50
patient clearly has meningitis... what are you worried about
if its menongococcemia (usually due to neisseria meningitidis) you are worried about waterhouse-friderichsen syndrome
WFS --> sudden vasomotor collapse and skin rash (large purpuric lesions on flank) due to adrenal hemorrhage
51
neonatal sepsis
```
temp instability (fever or hypothermia)
poor feeding
jaundice
CNS signs (lethargy, apnea, irritability)
abnormal WBC count (high or low)
left shift (bandemia)
```
dx via blood, urine, CSF
parenteral antibiotic therapy
52
treatment for pts with kawasaki
IVIG and aspirin
53
digeorge syndrome
chromosome 22q11.2 deletion
defective development of pharyngeal pouches
CATCH 22
Cardiac defects conotruncal (trunctus arteriosus or transposition)
Abnormal facies
Thymic hypo/a-plasia (T cell deficiency)
Craniofacial deformities (cleft palate)
Hypocalcemia/hypoparathyroidism
22nd chromosome
54
possible complications of bacterial meningitis in children > 1 month
- intellectual disabilities
- hearing loss due to inflammatory changes to cochlea)
- cerebral palsy
- epilepsy
55
epiglottitis
haemophilus influenzae, type b
respiratory distress, tripoding, sniffing, inspiratory stridor, dysphagia, drooling, high fever
dx via thumb sign (enlarged epiglottis)
endotracheal intubation to secure airway and start abx (ceftriaxone and vancomycin)
56
it pt falls with something in their mouth what are you most worried about and how does it present
-can also happen with any sort of neck manipulation/strain or penetrating trauma
traumatic carotid injury
- gradual onset hemiplegia
- aphasia
- neck pain
- thunderclap headache
dx via CT or MR angiography
57
loss of position and vibratory sense in an adolescent aged person
friedreich ataxia (GAA repeated.. seen in genetic testing)
- atrophy of dorsal columns and tracts
- hypertrophic cardiomyopathy
- kyphoscoliosis
- high foot arches
58
pt comes in with precocious puberty... what do you do
look at bone age
-if advanced --> look at basal LH, if low then do GnRH stimulation test and if still low its peripheral precocious puberty (caused by CAH). if basal LH is high its central precocious puberty and you should do a brain MRI to rule out a tumor before starting GnRH agonist therapy
* pts will be shorter cause estrogen stimulates growth plate closure
- if normal --> look for isolated breast or isolated pubic hair development and its probs just that but nothing else too concerning
59
how to manage parapneumonic effusions
small effusion AND no respiratory distress or hypoxia = oral antibiotics and close monitoring
medium/large effusion OR respiratory distress OR hypoxia = ultrasound, IV antibiotics, and drainage
60
neonatal polycythemia
hematocrit >65%
risk factors: excessive transfusion, intrauterine hypoxia, maternal diabetes
complications: highly viscous blood can limit organ perfusion and cause respiratory distress, hypoglycemia, and poor feeding
61
baby has chronic inspiratory stridor thats worse when supine
laryngomalacia
- collapse of supraglottic tissues on inspiration
- peak at 4-8 months
- dx via laryngoscopy (will see omega shaped epiglottis)
- reassurance with with close follow up, but can do supraglottoplasty for severe symptoms
62
kid pulled or swung by arm... what do you think
radial head subluxation (nursemaids elbow)
- immature annular ligament slips over head of radius and arm is flexed and pronated
- treat with hyperpronation of arm OR supination of forearm and flexion of elbow
63
most common cause of congenital heart disease
VSD
| do echocardiography to make sure its just this if you hear the murmur (holosystolic at left sternal border)
64
newborn boy presents with abdominal distension, poor urine output, and respiratory distress
posterior urethral valves
-respiratory distress is from oligohydramnios in utero and subsequent lack of lung development
-dx via voiding cystourethrogram
65
strabismus
ocular misalignment due to nasal deviation (estropia) or extropia
-may present with asymmetric red reflex/corneal light reflex or deviation during the cover test
* after 4 months this is not normal anymore*
- standard treatment is patching or blurring the normal eye to force the abnormal eye to correct itself
66
3 types of neonatal conjunctivitis
1. chemical (<24hrs), tearing after silver nitrate prophylaxis, give eye lubricant
2. gonococcal (2-5days), purulent discharge, give single dose IM 3rd gen cephalosporin
3. chlamydial (5-14days), watery discharge, give PO macrolide (azithro used over erythro cause erythro can cause pyloric stenosis)
67
focal headache, fever, early morning vomiting, sinus infection... next step?
concerning for brain abscess... get a CT scan of the head
| -will see a ring enhancing lesion
68
childhood onset fluency disorder
stuttering
69
duchenne muscular dystrophy
- age onset 2-3
- proximal muscle weakness (gower sign, calf pseudohypertrophy)
- dilated cardiomyopathy ---> get echo for this at initial dx
- scoliosis
- increased CK
- muscle turns into fat and connective tissue due to missing dystrophin gene
- treat with glucocorticoids
- wheelchair dependent by adolescence
- death by 20-30 due to respiratory/cardiac problems
70
whats the first thing you think of if a pt presents with pneumocystis jirovecii
HIV
| -decreased CD4+ T cells
71
how can you tell the difference b/w otitis media and externa
media has inflamed tympanic membrane (treat with amoxicillin)
externa has inflamed ear canal (treat with topical ciprofloxacin)
72
female pt who seems normal then has primary amenorrhea and you find out they have normal ovaries but no uterus
they probs also have abnormal development of the uterus, cervix, and upper third of the vagina
MULLERIAN AGENESIS
73
severe hepatosplenomegaly, anemia, thrombocytopenia, bony pain, fatigue, failure to thrive, delayed puberty
gaucher disease (AR)
- common in ashkenazi jews
- glucocerebrosidase deficiency
- treat with enzyme replacement
74
little kid with circular object with halo sign on x-ray... what do you do next?
probs a battery so you gotta endoscopically remove it cause batteries can cause corrosion, necrosis, and perforation
75
what type of fracture is concerning for abuse
metaphyseal corner/chip fracture (buckethandle fracture), common nutted (bunch of fragments) skull fracture
76
how to tell the difference b/w bruton agammaglobulinemia and common variable immunodeficiency
normal B cell count = CVID
| low B cells = brutons
77
painless, patchy, nonscarring hair loss in kids
alopecia areata
78
gamma tetramers on hemoglobin analysis points to what diagnosis
alpha-thalassemia (4 gene loss)
- hydrops fetalis/hemoglobin barts
- seen clinically as high output cardiac failure, anascara, death in utero
79
classic x-ray findings in foreign body aspiration
hyperinflation distal to obstruction and mediastinal shift away from affected side
-do a rigid bronchoscopy to identify and remove the object
80
how to tell the difference b/w tay-sachs and niemann-pick disease
niemann-pick disease has hepatosplenomegaly and areflexia (neither seen in TS- hyperreflexia)
*both have cherry red spot on macula
NP- sphingomyelinase deficiency
TS- beta-hexoaminidase A deficiency
81
adrenarche
pubic hair development
82
possible complications and treatments of infantile hemangiomas
- ulcerations/scarring
- vision impairment if near eye
- life-threatening if near airway
*can give beta-blockers (propranolol) if you are worried about one of these complications cause it works by causing vasoconstriction and inhibiting growth factors
83
baby presents with breast hypertrophy, swollen labia, whitish vaginal discharge (physiologic leukorrhea), uterine withdrawal bleeding
physiologic responses to transplacental maternal estrogen exposure
-no work-up indicated, observation and routine care
84
fanconi anemia
- inherited DNA repair defect causing bone marrow failure, presents b/w 4-12 years
- presents: thrombocytopenia ---> neutropenia ---> anemia
- pancytopenia, hyper/hypopigmented macules, short stature, abnormal thumbs, genitourinary malformations
- positive chromosomal breakage testing
- hematopoietic stem cell transplant
85
11p13 deletion syndrome is also called what... and what does this stand for
```
WAGR syndrome
Wilms tumor (most common renal malignancy in children)
Aniridia (absent iris)
Genitourinary abnormalities
Retardation
```
86
what should prompt you to do further workup for a urethral injury
- blood at urethral meatus
- hematuria
- difficulty voiding
*do retrograde urethrography
87
neurofibromatosis type 1
```
CICLOPSS
Cafe-au-lait spots
Intellectual disabilities
Cutaneous neurofibromas
Lisch nodules (pigmented iris hamartomas)
Optic gliomas
Pheochromocytomas
Seizures/focal neurological Signs (meningioma/bone lesion)
```
88
otitis media with effusion compared to acute otitis media
with effusion presents with no inflammation (fever and tympanic membrane mobility) and does not require anything for treatment
89
what happens if you see a positive target sign on ultrasound of bowels
intussusception
- reduce it with air (preferred) or water-soluble contrast enemas
- trouble pooping with currant jelly stools and streaks of blood
- sausage shaped abdominal mass
90
bitemporal hemianopsia, headaches, and endocrinopathies
craniopharyngioma (suprasellar mass)
91
joint pain and stiffness involving > 5 joints thats worse in the morning and better throughout the day
polyarticular juvenile arthritis
- usually adolescent/toddler female
- NSAIDs are first-line treatment
92
what are the respiratory and extrapulmonary symptoms in cystic fibrosis and what presents the same way?
- chronic sinopulmonary infections
- nasal polyps
- bronchiectasis
- digital clubbing
- pancreatic insufficiency (fat soluble vitamin deficiency)
- infertility due to absent vas deferens
- failure to thrive
*primary ciliary dyskinesia presents similarly, but the extrapulmonary symptoms are sinus inversus, infertility due to sperm immotility, and normal growth
93
parapneumonic effusion vs empyema
PNE --> sterile exudate in pleural space, pH > 7.2, glucose > 60, WBC < 50,000, negative gram stain/culture, treat with antibiotics
E --> bacterial invasion of pleural space, pH < 7.1, glucose < 60, WBC > 50,000, usually get false negative stain/culture, treat with antibiotics and drainage
94
patients with cystic fibrosis are more likely to get what bug at what age
before 20 ---> staph aureus
| after 20 ---> pseudomonas aeruginosa
95
what is associated with Rett syndrome
seizures
96
possible complications of sickle cell trait
- hematuria/papillary necrosis, hyposthenuria (painless hematuria, UTI, renal medullary cancer)
- splenic infarction (especially at higher altitudes), venous thromboembolism, priaprism
- exertional rhabdomyolysis
97
newborn with scalp swelling that does not cross suture lines
what if it does cross suture lines
cephalohematoma (aka. subperiosteal hemorrhage)
caput succedaneum crosses suture lines (usually seen after vertex delivery)
98
difference b/w duodenal and jejunal atresia on x-ray
```
duodenal = double bubble sign
jejunal = triple bubble sign
```
99
patient with coughing paroxysms, acute chest pain, shortness of breath, subcutaneous emphysema, crunching sound over the precordium (Hamman sign)
spontaneous pneumomediastinum
- evaluate with chest x-ray to confirm presence of mediastinal gas and rule out pneumothorax
- treat with rest, analgesics, and avoid valsalva maneuver
100
types of muscular dystrophy
1. Duchenne (x-linked recessive)--> progressive muscle weakness with calf pseudohypertrophy
2. Becker (x-linked recessive) --> milder weakness compared to duchenne
3. Classic myotonic (AD)--> facial and hand weakness with dysphagia and testicular atrophy
101
what rash is associated with lyme disease
erythema migrans
102
if someone has lymphnodes here you should be a little worried
supraclavicular or just generalized everywhere
103
most common causes of anemia in children
iron deficiency (hypochromia) or thalassemias (target cells)
104
most common childhood cancer and associated symptoms
ALL
- bone pain
- lymphadenopathy
- hepatosplenomegaly
- pallor/anemia
- petechiae
diagnose via bone marrow evaluation (> 25% lymphoblasts)
105
child recently recovered from diarrheal illness then gets thrombocytopenia
HUS from ecoli
106
baby presents with acute neurological changes, bulging fontanelle, and increasing head circumference
interventricular hemorrhage
| -risk factors: ruptured germinal matrix vessels, prematurity, very low birth weight
107
pt presents with respiratory distress within hour of birth, absent breath sounds on one side of lung, concave abdomen with barrel-shaped chest
congenital diaphragmatic hernia
- incomplete fusion of pleuroperitoneal folds
- herniation of bowel into chest
- pulmonary hypoplasia and hypertension
treat with: endotracheal intubation, gastric decompressing (NG tube), and surgical correction
108
what lab findings do you expect to see in a pt with galactosemia
GALT deficiency so you cant reduce galactose to glucose
- increased bilirubin, AST, ALT (jaundice, vomiting, cataracts, increased risk of ecoli sepsis)
- low glucose
- metabolic acidosis
- positive urine reducing substances
- dont breastfeed these babies
109
pathophysiology of reye syndrome
microvesicular fatty infiltration
110
CHARGE syndrome
```
Coloboma (missing eye tissue)
Heart defects (TOF, VSD)
Atresia choanae (tube doesnt go past nares)
Retardation of growth/development
Genitourinary anomalies
Ear abnormalities (hearing loss)
```
Other findings ---> anosmia, cleft palate, hypotonia
Dx ---> clinical and CHD7 gene testing
111
VACTERL syndrome
```
Vertebral
Anal atresia
Cardiac
Tracheo-
Esophageal fistula
Renal
Limb
```
112
risk factors that increase the risk for respiratory distress syndrome
- prematurity
- male sex
- perinatal asphyxia
- maternal diabetes
- c-section without labor
113
Metatarsus adductus vs Congenital clubfoot
Metatarsus adductus
- most common congenital foot deformity
- flexible positioning, medial deviation of forefoot, neutral position of hindfoot
- treat with reassurance
Congenital clubfoot
- rigid positioning
- medial/upward deviation of forefoot & hindfoot
- hyper-plantar flexion of foot
- treat with serial manipulation & casting; surgery for refractory cases
114
what is scarlet fever and how does it present
- due to strep pyogenes
- clinical features ---> fever, pharyngitis, tonsillar erythema/exudates, strawberry tongue, tender anterior cervical nodes, sandpaper rash (peeling of hands and feet)
- dx ---> rapid strep antigen test, throat culture
- treatment ---> penicillin (amoxicillin)
115
symptoms for CVID
- recurrent respiratory and GI infections
- autoimmune diseases
- chronic lung diseases
- GI disorders
- decreased IgG and IgA/IgM with no responses to vaccination
- treat with immunoglobulin replacement therapy
116
bizarre behavior and abnormal liver function tests
wilsons disease
117
trachoma
due to infection with chlamyida A, B, and C
- acutely presents with follicular conjunctivitis and inflammation and conjunctival thickening
- due to repeated or chronic infection causes inversion of the eyelashes and scarring of the cornea
- use azithromycin and maybe eyelid surgery if needed
118
high lead capillary blood testing
redo the test with venous lead levels instead cause it could be falsely high in capillaries
119
testicle that transilluminates, painless scrotal swelling
probs a hydrocele, reassure and observe
| -usually resolves by age 1
120
pt under 3 or over 60 with underlying renal or cardiac condition gets a large/fast transfusion then has pulmonary edema and respiratory distress
TACO / Transfusion associated circulatory overload
| treat with respiratory support with O2 and diuresis with furosemide
121
complications of infectious mononucleosis
acute airway obstruction
autoimmune hemolytic anemia and thrombocytopenia
splenic rupture
treatment includes corticosteroids
122
newborn with cyanosis when feeding that gets better with crying
choanal atresia (part of CHARGE syndrome)
- failure of posterior nasal passage to canalize during the first trimester
- can diagnose by passing catheter through nares
123
rash starting on face then traveling down that spares palms and soles, lymphadenopathy, patchy erythema on mouth, arthraligas/arthritis
rubella
124
baby with persistent oxygen requirement with tachypnea, rhonchi, and radiology showing haziness and decreased lung volumes
bronchopulmonary dysplasia
| -risk factors ---> prematurity
125
bronchiectasis
result of airway remodeling and thickening due to chronic inflammation
-usually associated with cystic fibrosis
126
cholesteatomas
accumulation of keratin debris and squamous epithelial cells within a tympanic membrane retraction pocket
- symptoms include persistent otorrhea and conductive hearing loss
- exam shows pearly white mass behind an intact tympanic membrane
127
in a pt with tetrology of fallot why does a knee to chest position make them feel better?
increases systemic vascular resistance which causes less right to left shunting
128
biggest risk factors for cerebral palsy
prematurity and low birth weight
129
steps for routine newborn care
1. dry and stimulate
2. clear airway as needed by suctioning oropharynx
3. provide warmth by skin to skin
130
what causes hypertrophic cardiomyopathy
asymmetrical left ventricular hypertrophy leading to left ventricular outflow obstruction
131
patient with papilledema on retinal exam with headaches and vision changes (blurry and bilateral blind spots)
idiopathic intracranial hypertension
132
what neuro disorder is assocaited with renal angiomyolipoma, ash-leaf spots, angiofibromas, shagreen patch, hamartomas, epilepsy, intellectual disabilities, autism/ADHD, cardio rhabdomyomas
tuberous sclerosis
133
patient with increased MCHC and bilirubin but decreased MCV
hereditary spherocytosis
134
head injury with glascow scale = 15 and vomiting
head CT without contrast (contrast can look like blood on CT)
or
observe for 4-6 hours
135
```
an hour after transfusion the patient has fever, flank pain, and hemoglobinuria
if transfusion is continued....
-DIC
-acute renal failure
-shock
```
ABO incompatibility
136
most common CNS tumor in kids with new onset of seizures
low-grade astrocytoma
137
3 types of regular conjunctivitis
1. viral (uni/bi-lateral), 1-2 weeks, watery/mucoid, viral prodrome
2. bacterial (uni/bi-lateral), 1-2 weeks, purulent, unremitting ocular discharge
3. allergic (always bilateral), < 30mins to perennial, watery, ocular pruritus
138
baby gets a UTI, what do you do after you treat them
1. antibiotics
2. renal ultrasound
3. voiding cysturethrogram if one of the following indications apply
- >2 febrile UTIs
- abnormal renal ultrasound
- fever with bacteria other than Ecoli
- signs of chronic kidney disease
139
baby with ruptured germinal matrix vessels... what do you think of
intraventricular hemorrhage
risk factors: prematurity and very low birth weight
babies may present with seizures, full fontanelle, and anemia
dx via cranial ultrasound
140
hemolytic uremic syndrome triad
1. hemolytic anemia
2. thrombocytopenia
3. acute kidney injury
*prodromal diarrhea
141
how to treat a SCFE and who is at higher risk of getting it
treat with physis stabilization and screw fixation
| -hypothyroid kids are at higher risk due to impaired ossification of growth plate
142
suspected developmental dysplasia of the hip leads to what next step
age < 4 months: hip ultrasound
| age > 4 months: hip radiograph
143
what do you expect to see in a pt with acetaminophen toxicity
nausea, vomiting, RUQ pain, potential liver failure, and death
144
how to work up bilious emesis in a patient refusing to feed
1. stop feeds, NG tube decompression, IV fluids
2. abdominal x-ray
- free air, hematemesis, unstable vital signs ---> surgery
- dilated loops of bowel ---> contrast enema (meconium ileus or hirschsprungs)
- NG tube in misplaced duodenum/gasless abdomen ---> upper GI series to look for malrotation
- double bubble sign ---> duodenal atresia
145
treatment options for tourette syndrome
1. habit reversal
2. dopamine antagonists
3. alpha-2 receptor agonists
146
perianal dermatoses
1. spares skin folds and creases
2. beefy-red rash involving skin folds with satellite lesions
3. bright sharply demarcated erythema over perianal area
1. contact dermatitis
2. candida
3. perianal strep
147
what are the two fragility tests for RBCs to test for hereditary spherocytosis
eosin-5-maleimide (EMA) binding test
| acidified glycerol lysis test
148
blue-gray patches all over the skin
| -more common in asian and african americans
congenital dermal melanocytosis (mongolian spots)
- usually on lower back and butt
- do nothing, just reassurance (usually fade on their own)
149
patient with hemophilia A is getting recombinant factor 8, but what happens if they are still bleeding into their joints
they likely have inhibitor development, so their body is inhibiting the recombinant factor 8 they are getting and they need something to bypass factor 8 to help with bleeding instead
-occurs in 25% of patients
150
most common malignant pediatric brain tumor
usually pts have cerebellar problems with obstructive hydrocephalus cause it compresses the 4th ventricle (papilledema and abducens nerve palsy)
medulloblastoma (posterior fossa tumor)
| -treat with resection, craniospinal radiation, and chemotherapy
151
mupirocin
topic antibiotic used for skin staph with impetigo (only skin involvement)
152
bag of worms mass in scrotum that does not transilluminate
varicocole
primary- compression of left renal vein b/w SMA and aorta/incompetent venous valves, pubertal onset, left sided, decompresses when supine, reassurance and observation
secondary- extrinsic compression (renal or retroperitoneal mass) of IVC/venous thrombosis, prepubertal onset, right sided, persists when supine, abdominal ultrasound
153
asymptomatic neonate with scattered, erythematous papules and pustules
erythema toxicum neonatorum
| -no treatment needed, usually self resolves within 2 weeks
154
diamond- blackfan anemia
- congenital defect in erythroid progenitor cells leading to increased apoptosis of RBCs leading to profound anemia
- macrocytic anemia (normal platelets and WBCs)
- craniofacial anomalies
- triphalangeal thumbs
- pts usually also have short stature, cleft palate, and webbed neck
- increased risk of malignancy
- treat with corticosteroids and RBC transfusions
155
baby with biphasic stridor that improves with neck extension
vascular ring (anomalous branch of aortic arch or pulmonary artery) compressing airway
- great vessels encircle and compress the trachea
- barium swallow can identify indent in esophagus
- dx can be confirmed with contrasted CT or MR angiography
156
septic arthritis
pathogens: under 3 months- staph, group B strep // over 3 months- staph, group A strep
clinically: acute onset joint pain/swelling/limited motion, refusal to bear weight, fever
dx: increase WBC/ESR/CRP, blood culture, joint aspiration, effusion on ultrasound/MRI
treatment: joint drainage/debridement and IV antibiotics
157
if someone is presenting with guillan-barre what do you wanna do as the next step?
- life threatening complication of these patients is respiratory failure (seen in 30% of patients)
- monitor autonomic and respiratory function via spirometry
- IVIG and plasmapheresis
158
other names for avascular necrosis of bone and what does it look like
Legg-Calve-Perthes disease // idiopathic osteonecrosis
- boys age 3-12
- insidious hip pain and limp with restricted abduction and internal rotation
- positive trendelenburg
- treat with non-weight bearing, splinting, and possible surgery
159
unilateral pain on plantar surface of foot
| pain is worse when first stepping out of bed then gets better throughout the day
plantar fasciitis
160
kid does running/jumping sports and has tender base of heel
calcaneal apophysitis
161
PDA-dependent congenital heart disease
- coarctation of the aorta
- D-transposition of the great arteries
- hypoplastic left heart syndrome
- total anomalous pulmonary venous connection
- tricuspid atresia
*give PGE1
162
summer months, fever, pharyngitis, gray vesicles/ulcers on the oropharynx (usually b/w ages 1-7)
Coxsackie A-virus
| -supportive treatment
163
fever, pharyngitis, erythematous gingiva, clusters of vesicles on anterior oral mucosa/lips (6 months-5 years)
Herpes Simplex Virus
| -give oral acyclovir
164
marfanoid body habitus...what do you think?
marfans ---> aortic root dilation
homocystinuria ---> intellectual disability, thrombosis
165
what increases the risk of a brain abscess
congenital cyanotic heart diseases
166
what causes the majority of viral meningitis
enteroviruses
167
what is the most common complication of sickle cell disease
painless hematuria resulting from sickling in the renal medulla
168
what does a white reflex (leukocoria) in the eye mean?
opacity of the lens (cataracts) or tumor (retinoblastoma)
169
patient with facial and hand swelling that occurs during stressful times in a person with family history of hypertension
- colicky abdominal pain, vomiting, and diarrhea
- low C1 and C4
Hereditary Angioedema
C1 inhibitor deficiency/dysfunction
excessive bradykinin
170
Ramsay Hunt syndrome
classic triad of herpes zoster oticus
- severe ear pain
- ipsilateral facial paralysis
- vesicular rash (can be described as crusted eruptions)
171
baby drinking milk with vomiting/regurgitation, eczema, and bloody stools
milk allergy protein
| -elimination dairy and soy protein from diet
172
baby presents with painless hematochezia
meckel diverticulum
- 2% prevalence
- presents at age 2
- 2x more likely in males
- within 2 feet of ileocecal valve
*diagnose with technetium-99m pertechnetate scan which can identify ectopic gastric mucosa
173
acute iron poisoning
```
abdominal pain
diarrhea
hematemesis
hypovolemic shock within a few hours due to gastrointestinal losses
anion gap metabolic acidosis
x-ray may show radiopaque tablets
```
174
complications of pediatric sleep apnea
- poor growth (failure to thrive)
- poor school performance
- cardiopulmonary (hypertension and structural heart changes)
175
pathology finding in post strep glomerulonephritis
mesangial immune complex deposits
176
how to manage a patient with duodenal atresia
1. discontinue enteral feeds
2. nasogastric tube decompression
3. surgical repair
177
patients with severe asthma with signs of respiratory failure (altered mental status, respiratory acidosis, hypoxemia, hypercarbia) should have what...
endotracheal intubation and mechanical ventilation
178
hypertrophy of peyers patches indicate what
possible illness that could increase this lymphoid rich area
179
if you see a patient with nephrotic syndrome and active hepatitis B what do you think of
membranous nephropahty
180
at what point are you worried about bowed legs?
it could be a normal finding up until 2 years but make sure they are drinking enough milk and getting vitamin D and calcium
181
recurrent sinopulmonary and gastrointestinal infections after 6 months
x-linked agammaglobulinemia
- absence of lymphoid tissue on exam
- decreased immunoglobulins and b-cells
- normal t-cell concentration
- no response to vaccinations
*treat with IVIG and prophylactic abx if severe
182
mediterranean background and microcytic anemia... what do you think of? (if everything else also fits)
beta-thalassemia
183
what do you expect to see in a pt with iron deficiency
low erythrocyte count and increased RBC-WD
184
most common cause of congenital hypothyroidism worldwide
thyroid dysgenesis
185
how to treat beta-thalassemia
these pts are transfusion dependent
| -this increases the risk of iron overload so they need chelation therapy to offset this risk
186
when to think of necrotizing enterocolitis
risk factors ---> prematurity, very low birth weight ( <3.3lbs), enteral feeding with formula
clinical features ---> vital sign instability, lethargy, bilious emesis, bloody stools, abdominal distention
x-ray findings ---> pneumatosis intestinalis, portal venous gas, pneumoperitoneum
treatment ---> bowel rest/parenteral nutrition, broad-spectrum abx, maybe surgery
187
- pt age 2 or less usually
- abdominal mass
- periorbital ecchymoses
- opsoclonus/myoclonus syndrome
neuroblastoma (neural crest origin, affects neural medulla and sympathetic chain)
- periorbital ecchymoses are from orbital metasteses
- spinal cord compression from epidural invasion (dumbbell tumor)
- elevated catecholamine metabolites
- small round blue cells on histology
- N-myc gene amplification
188
primary ciliary dyskinesia
mutations in ciliary dynein arms so cilila are dysmotile
- recurrent sinopulmonary infections
- bronchiectasis
- sinus inversus (kartagener syndrome)
- dx: low nasal nitric oxide levels, genetic testing, bronchoscopy and electron microscopic visualization of ciliary abnormalities
189
vitamin A effect on CSF
impair CSF resorption leading to increased ICP (tetracyclines and growth hormone also increase ICP)
190
if you see a patient who is anorexic then gets admitted and starts feeding what should you be worried about it
refeeding syndrome
- carb intake stimulates insulin which promotes cellular uptake of phosphorus, potassium, and magnesium
- clinically presents with arrhythmias and cardiopulmonary failure
191
how does systemic juvenile idiopathic arthritis present
| -age < 18
- arthritis in more than 1 joint for more than 6 weeks
- quotidian fever for more than 2 weeks
- evanescent rash
- hepatosplenomegaly
- lymphadenopathy
192
polyarticular juvenile idiopathic arthritis vs oligoarticular
poly: arthritis in more than 5 joints, may be complicated by uveitis
oligo: arthritis in less than 5 joints, may be complicated by uveitis
193
breast feeding vs breast milk jaundice
breast feeding: first week of life, insufficient intake of breast milk leading to decreased bilirubin elimination and increased enterohepatic circulation, presents as suboptimal breastfeeding and signs of dehydration
breast milk: starts at age 3-5 days and peaks at 2 weeks, high levels of beta-glucuronidase in breast milk deconjugate intestinal bilirubin and increase enterohepatic circulation, presents as adequate breast feeding and normal exam otherwise
194
hyposthenuria
kidneys inability to concentrate urine so you have a low specific gravity (can be a complication of sickle cell
195
contact dermatitis due to poison ivy or nickel
type 4 delayed t cell mediated hypersensitivity response
196
how to treat a baby with food-protein induced allergic proctocolitis causing a well-appearing infant to have bloody stools
eliminating maternal consumption of dairy and soy products or switching to hydrolyzed formula
197
patients with a FIXED cryptorchidism are at higher risk of what
testicular germ cell tumor even after its fixed
198
what are the 2 definitions of primary amenorrhea
1. 13 or older without secondary sex characteristics
2. 15 or older with secondary sex characteristics
BOTH HAVE NO PERIODS YET
199
colic
cyring for no apparent reason > 3hrs/day for > 3days/week
200
what are the two most common comorbid diseases in someone with tourette syndrome
ADHD and OCD
201
keratosis pilaris
retained keratin plugs in hair follicles
| -treat with emollients and topical keratolytics (salicylic acid, urea)
202
what is the most common congenital heart anomaly in pts with trisomy 18
VSD, but could be anything... pay attention to the murmur type
203
delayed muscle relaxation with cognitive and behavioral problems in kids
myotonic dystrophy
204
macrocytic anemia in sickle cell pt
probs folate deficiency from all the RBCs being destroyed and them not eating enough folate
205
limited upward gaze
upper eyelid retractions (Collier sign)
pupillary abnormalities (reactive to accomodation but not light)
parinaud syndrome usually due to pinealoma
206
when do you see basophilic stippling (lots of little blue dots in RBCs)
thalassemias and lead/heavy metal poisoning
207
when do you see howell-jolly bodies (big and dense blue dots in RBCs)
nuclear remnants of RBCs that are usually removed by the spleen but are seen in pts with asplenia or sickle cell with functional asplenia
208
pellagra
```
4 Ds
Diarrhea
Dermatitis
Dementia, depression, distraction
Death
```
Associated with malabsorptive diseases, alcoholism, anorexia
209
list the common etiologies of the pediatric stroke
```
sickle cell disease (most common)
prothrombotic disorders
congenital cardiac disease
bacterial meningitis
vasculitis
focal cerebral arteriopathy
head/neck trauma
```
210
patient with asymptomatic proteinuria... next step?
first morning urine
211
microcytic anemia, T1DM, growth delay
celiac
| -also associated with dermatitis herpetiformis
212
lytic bone lesion, skin lesions/eczema, lymphadenopathy, hepatosplenomegaly, pulmonary cysts/nodes, central diabetes insipidus
langerhans cell histiocytosis
213
neisseria meningitis post-exposure prophylaxis
give 1 dose of any of these immediately to any and all contacts regardless of vaccination status
rifampin
ceftriaxone
ciprofloxacin (adults only)
214
postconcussion syndrome
headache and sleep disturbance for 1 month or more after a concussion
- no other abnormalities
- supportive care cause pts get better w/i 3 months
215
how to tell if pt had a cookout with friends and everyone got sick... which virus or bacteria did it?
staph aureus: ingestion of preformed toxin so vomiting begins 6 hours after eating
bacillus cereus: usually due to reheated rice and ingestion of preformed toxin so vomiting begins 6 hours after eating
norovirus: vomiting and watery diarrhea about 1-2 days after eating, usually in schools/on cruise ships, person-to-person contact or via food, fecal leukocytes not seen, supportive treatment
216
trisomy 18 vs trisomy 13
```
Edwards (18)
Prominent occiput
Rocker-bottom feet
Intellectual disability
Nondisjunction
Clenched fists (with overlapping fingers)
Ears low set
micrognathia (small jaw)
congenital heart disease (VSD)
limited hip abduction
omphalocele
renal defects
death usually by age 1
```
```
Patau (13)
severe intellectual disability
rocker-bottom feet
microphthalmia
microcephaly
cleft liP/Palate
holoProsencephaly
Polydactyly
cutis aPlasia
congenital heart disease
Polycystic kidney disease
omphalocele
death usually by age 1
```
217
patient has tumor causing ataxia and dysmetria
medulloblastoma or pilocytic astrocytoma
218
tumor causing horner syndrome
tumor is neuroblastoma
horner syndrome: ptosis, miosis, anhidrosis
219
sensory neural hearing loss is due to what
damage to inner ear or auditory nerve canal
CMV can cause this delayed after the kid grows up
220
how are measles contracted
airborne (highly contagious)
221
how to treat wiscott-aldrich
WATER = Wiscott-Aldrich Thrombocytopenia Eczema Recurrent infections
treat with hematopoietic stem cell transplant
222
infant is sneezing, irritable, vomiting, and loose stools
heroine toxicity in infant
223
infant is jittery, excessive sucking, and hyperactive moro reflex
cocaine toxicity in infant
224
von hippel lindau syndrome
benign tumors: retinal hemangioblastomas
malignant tumors: renal cell carcinoma (bilateral)
pheochromocytomas
angiomatosis
225
most common brain tumor in children
low grade astrocytoma
| -in parietal lobe
226
kid has bony pain only at night but otherwise is totally fine
growing pains usually only in the lower extremity b/w 2-12 years old
-do reassurance, massage, over the counter meds
227
when to initiate lead chelation therapy
if levels are at or above 45 ug/dl
228
how to differentiate TEN from staph scalded skin syndrome
TEN has mucous involvement
229
kid with high fever, abdominal cramping, mucoid/bloody diarrhea, and can be associated seizures
shigella sonnei
230
shearing of emissary veins during delivery causing blood b/w periosteum and aponeurosis
- fluctuant scalp swelling that can move, cross suture lines, and expand for days after delivery
- tachycardia and pallor can occur due to blood loss
subgaleal hemorrhage
231
infant with convulsions, periods of apnea, respiratory depression, and altered muscle tone
fontanels may be tense but no scalp swelling
subdural hemorrhage
232
viral prodrome then rash with oval lesions in christmas tree pattern
pityriasis rosea
233
how to manage pts with congenital QT prolongation
pts are at risk for syncope, ventricular arrhythmias, and sudden cardiac death
- avoid electrolyte derangements and Ca2+ channel blockers
- use beta blockers with pacemaker placement to prevent cardiac arrest
234
erythema infectiosum rash
slapped cheek parvo b19 rash
235
synovial fluid leukocyte count of what should lead to the dx of septic joint?
over 50,000
| -treat with vancomycin and ceftriaxone
236
why dont you use tetracyclines in pts under the age of 8
tooth discoloration
237
varicella post-exposure prophylaxis protocol
history of immunity with less than 2 vaccines (usually at age 1 and 4) ---> if immunocompetent then just give varicella vaccine, if immunocompromised then give VZIG
if all vaccines (age 1 and 5) were given then just observe
238
baby with recurrent sinopulmonary infections and decreased antibody production (with decreased antibody response to vaccines)
x-linked agammaglobulinemia
239
what happens to insulin sensitivity when someone exercises
insulin sensitivity increases so easier to become hypoglycemic
240
whats another word for amblyopia
lazy eye
| -patch the other eye to help fix this
241
definition of fetal growth restriction and what types could it be
fetal weight < 10th percentile
or
birth weight <3rd percentile
symmetric
- everything is small
- due to problem early in pregnancy (genetic condition, congenital infection)
asymmetric
- everything small but head is normal sized
- due to uteroplacental insufficiency (maternal chronic htn) or maternal malnutrition in 2nd and 3rd trimester
242
when you see a spiral fracture (diagonal line on the end of the bone) in an ambulatory toddler, what do you think of
- usually after a twisting injury during a low impact fall
| - nothing concerning this is normal in little kids as long as the story fits
243
cauliflower looking tumor in a ventricle
choroid plexus papilloma
- highly vascular neuroepithelial tissue found within the ventricles producing CSF and increases CSF production
- can cause hydrocephalus
244
newborn baby comes with a pretty big bump (nonfluctuant scalp swelling) on their head but is doing well otherwise... what do you think of
cephalohematoma
- collection of blood b/w skull and periosteum (subperiosteal space)
- does not cross suture lines
- trauma due to birth
245
when should kids be screened for depression
all adolescents age 12 and above should be screened annually for depression
246
when should a front facing car seat be used
rear-facing is better cause it protects the head/spine collision and should be used till the kid cant fit anymore
- switching should not occur before age 2
- many children remain rear-facing until age 4
247
what are the most common drugs that cause drug-induced hemolytic anemia
antiinflammatory drugs: diclofenac
cephalosporins: ceftriaxone
penicillins: pip-tazo
248
newborn with diffuse scalp swelling and signs of blood loss (pallor, anemia, tachycardia)
-diffuse fluctuant scalp swelling extends beyond suture lines and possibly even to neck
subgaleal hemorrhage
- can be fatal
- caused by rupture of emissary veins upon scalp traction during delivery
- blood b/w periosteum and galea aponeurotica
- more common in vacuum assisted deliveries
- usually due to birth and can happen in vaginal or c-section too
249
how to treat a stroke in sickle cell pts
exchange transfusion (replacing blood with allogenic blood)
250
if a pt has an abnormal red reflex, what is the next step
dilated funduscopic exam to detect retinoblastoma
| -strabismus (lazy eye) can cause an asymmetric corneal light and red reflex but you should still check for rb
251
greatest risk factor for atraumatic splenic rupture is what
stretching of splenic capsule due to infection or malignancy (leukemia)
-think infectious mono
252
pt presents with night blindness, progressive visual field loss (midperiphery), and decreased visual acuity (late finding)
funduscopic findings: retinal vessel attenuation, optic disc pallor, abnormal retinal pigmentation
retinitis pigmentosa
- genetic mutation causing loss of photoreceptors
- progressive retinal degernation
- symptom oset from age 10 through adulthood
prognosis: most are legally blind by age 40
253
when treating bronchiolitis (RSV) when do you give palivizumab (if not its just supportive care)
<2 months (29 weeks)
chronic lung disease of prematurity
hemodynamically significant congenital heart disease
254
all preterm neonates born less than 32 weeks gestation should undergo what screening
head ultrasound at 1-2 weeks
-look for intraventricular hemorrhage due to the presence of the germinal matrix (fragile super vascular area in the brain)
255
most common cause of macrocephaly
head circumference > 97th percentile
| -benign familial macrocephaly due to megaloencephaly (increased brain parenchyma volume)
