Pediatrics Flashcards
APGAR?
- Appearance (Blue/pale, acrocyanosis, pink)
- Pulse (absent, <100, >100)
- Grimace (absent, with high stimulation, with normal stimulation)
- Activity (none, flexion, resistance to extension)
- Respiration (absent, irregular, strong)
Normal: 7-10
Baby with accrocyanosis, pulse 75, grimace with stimulation, resistance to extension and irregular respirations.
APGAR?
APGAR= 7
acrocyanosis= 1 pulse=1 Grimace=2 activity=2 respiration=1
Term baby with grunting. CxR: hyperextended and edema lungs.
Dx and tx?
Transient tachypnea of the newborn (TTN)
Tx: positive pressure ventilation (PPV)
Immature infant with difficutly breathing. CxR: hypo extended lung with atelectasis
Dx and tx?
Respiratory Distress Syndrome (RDS)
Tx: intubation + surfactant
Baby large for gestational age, the mother with DM. Baby with jitteriness, tremors, lethargy, poor feeding.
Dx, next step and tx?
Hypoglycemia
Next step: Look for cause (infection)
Tx: 2mL/kg of D10W and recheck
Ppx for eye infections in newborns?
Erythromycin drops
Screening for retinibastoma in new born?
Red reflex
Pre-term infant with increased demands of O2 for >28 days.
CxR: Ground glass opacity
Dx, tx?
Bronchopulmonary dysplasia (BPD)
- Post-natal surfactant to baby
- Ante-natal steroids to mom
Pre-mature infant with increased FIO2 requirements who undergoes eye exam, which shows neovascularization.
Dx, tx and long-term consequences?
Retinopathy of prematurity (ROP)
Tx: photoablation
F/U: early glaucoma
Pre-mature patients with bulging fontanels, seizure, coma.
Dx, next step, tx?
Intraventricular hemorrhage
Next step: Cranial doppler
Tx: Surgery (VP shunts, drains)
Pre-mature infant with bloody bowel movement.
Abdominal xR showing air in the wall of the bowel
Dx and tx?
Necrotizing enterocolitis
Tx:
- NPO
- IV antibiotics against gram negatives
- Total parenteral nutrition
New-born who during the first exam you notice No anal opening.
Next step?
Evaluate VACTREL syndrome • Vertebral anomalies: U/S of sacrum • Anus (imperforate): Cross table xR • Cardiac problems: Echocardiogram • Traqueo-esophageal fistula: Nasogastric tube down the nostril and take xR • Esophageal atresia: Nasogastric tube • Renal: Voiding cystourethrogram • Limb: xR for wrist
New-born who during the first exam you notice No anal opening.
Cross table xR shows that blind end is near to the skin
Tx?
surgery right away
New-born who during the first exam you notice No anal opening.
Cross table xR shows that blind end is far from the skin
Tx?
Colostomy first, surgery once bigger (before toilette training)
New-born, no meconium 48 hrs after delivery. The mother is undocumented immigrant and didn’t have prenatal care.
Dx, next step, tx and f/u?
Meconium Ileus
Next step: xR with air-fluid levels with a gas-filled plug.
Tx: Water enema
F/U: Confirm Cystic Fibrosis dx with sweat chloride test
• If (+), supplement with Vitamins A, D, E, and K, give pancreatic enzymes, and recommend pulmonary toilet
New born with failure to pass meconium, palpable colon and explosive diarrhea on digital exam.
Dx, next step and tx?
Hirschsprung’s
Next steps:
o xR showing dilated proximal colon (normal) and a normal looking distal colon (abnormal)
o Contrast enema to see the transition point
o Gold standard: Bx showing no plexus
Tx: Resection of colon without plexus
Baby with chronic diarrhea and overflow incontinence.
Dx, next step and tx?
Hirschsprung’s
Next steps:
o xR showing dilated proximal colon (normal) and a normal looking distal colon (abnormal)
o Anal-rectal manometry showing increased tone (because of the lack of inhibitory neurons)
o Gold standard: Bx showing no plexus
Tx: Resection of colon without plexus
Child in toilet training or entering school who has constipation, overflow incontinence and encopresis.
Dx and tx?
Voluntary holding
Tx:
• Stool softeners and motility agents + behavioral intervention (tell the kid that is ok to poop)
• Desimpactation under anesthesia
Baby with projectile bilious vomiting. Normal pregnancy, no risk factors, no polyhydramnios.
xR showing double bubble with normal gas pattern beyond
Dx and tx?
Malrotation/volvulus
Tx:
o NG tube to decompress
o Surgery
Baby with down syndrome and projectile green vomit. In-utero had polyhydramnios.
xR showing double bubble without gas beyond
Dx?
Duodenal atresia or annular pancreas
Tx: surgery (during the surgery you differentiate with annular pancreas)
Baby with projectile green vomit. Mom with cocaine/tobacco use during pregnancy.
xR showing double bubble with multiple air-fluid levels
Dx?
Intestinal atresia
Tx: Surgery
Patient with projectile non-biliary emesis at day 1, gurgling and bubbling with respirations.
Dx, next step and tx?
Tracheoesophageal fistula
Next step: NG tube that coils on xR
Tx:
o Parenteral nutrition
o Surgery
Baby male who was eating normally but at weeks 2 to 8 has projectile non-biliary emesis. On physical exam, you feel and olive-shaped mass and see visible peristaltic waves.
Dx, next step and tx?
Pyloric stenosis
Next step:
o U/S showing a donut sign
o CMP showing hypochloremic, hypokalemic, metabolic alkalosis (↓Cl, ↓K, ↑pH, ↑HCO3)
Tx:
o IVF and correct electrolytes
o Surgery (pyloromyotomy)
Baby with jaundice. ↑ Conjugated bilirubin.
Next step?
HIDA scan, hepatic U/S, sepsis evaluation, metabolic evaluation.
Baby with jaundice. ↑ unconjugated bilirubin.
Next step?
Coombs test
If + –> isoimmuniazation
Baby with jaundice. ↑ unconjugated bilirubin. Coombs test negative, high hemoglobin.
Possible dx?
Twin-twin transfusion, maternal-baby transfusion, delayed cord clamping
Baby with jaundice. ↑ unconjugated bilirubin. Coombs test negative, normal hemoglobin, reticulocyte count +.
Possible dx?
Hemolysis (G6DP deficency, spherocitosis)
Baby day 4 with jaundice. ↑ unconjugated bilirubin. Coombs test negative, normal hemoglobin, reticulocyte count negative.
Dx and tx?
Breastfeeding jaundice (low quantity of milk)
Tx: Feed baby more (formula supplementation)
Baby day 12 with jaundice. ↑ unconjugated bilirubin. Coombs test negative, normal hemoglobin, reticulocyte count negative.
Possible dx?
Breast milk jaundice (low quality of milk)
Tx: Feed baby with hydrolyzed formula (formula replacement)
Baby with scaphoid abdomen.
Dx, next step and tx?
Diaphragmatic Hernia
Next step: Babygram
Tx:
- Surgical repair
- Supplemental surfactant may be needed
Abdominal wall defect right of midline and without a membrane.
Dx and tx?
Gastroschisis
Tx:
- Cover viscera in a sterile bag and place saline-soaked gauze over extruded contents to prevent desiccation and infection.
- Place NG tube
- IVF
- Covered silo to allow the extruded contents to gradually re-enter the abdomen.
Baby with abdominal wall defect in the midline and covered with a membrane.
Dx and tx?
Omphalocele
Tx:
- Cover viscera in a sterile bag and place saline-soaked gauze over extruded contents to prevent desiccation and infection.
- Place NG tube
- IVF
- Covered silo to allow the extruded contents to gradually re-enter the abdomen.
Midline defect, wet with urine, shiny and red, no bowel inside the sac.
Dx and tx?
Exstrophy of the Bladder
Tx: Surgery
Patient with worsening jaundice (direct hyperbilirubinemia) at about two weeks.
US shows no biliary treee.
Dx, next step and tx?
Biliary Atresia
Next step: HIDA scan 5-7 days after phenobarbital stimulation
Tx: Surgery
Complications of cleft palate/lip
Failure to thrive , otitis media, feeding difficulties, possible hearing difficulties, and speech pathology
How are Neural Tube Defects diagnosed in prenatal care?
- ↑AFP
- U/S
Complications Neural Tube Defects
- Arnold Chiari malformation
- Hydrocephalous
- Learning difficulties
- Focal neurological deficit below the level of the defect
Tuff of hair in the back of a baby.
Dx?
Occulta Neural Tube Defects
Failure to thrive affects (in order)
- Weight
- Height
- Head circumference
Gross motor development milestones of a child
2 mo Lift head 4 mo Roll over 6 mo Sit up 1 yr Walk 2 yrs Steps 3 yrs Tricycle 4 yrs Hop (jumping on one foot) 5 yrs Skip
Fine motor development
2 mo 4 mo 6 mo 1 yr 2 yrs 3 yrs Circle 4 yrs Cross 5 yrs Triangle
Speech development
2 mo 4 mo 6 mo 1 yr 1 word 2 yrs 2 word 3 yrs 3 word 4 yrs 4 word 5 yrs 5 word
Social development
2 mo Social smile 4 mo 6 mo Stranger danger 1 yr Separation anxiety 2 yrs 3 yrs 4 yrs 5 yrs
An 8-month infant with an episode of change in colour, tone, breath or responsiveness. Duration was less than 1 min. No CPR performed. First time that this happens.
No findings or physical exam findings
Dx and next step?
Brief Resolved Unexplained Event (BRUE)
Next step: No further investigations required, just reassure parents
If findings on history or physical exam, monitor and investigation accordingly
Prevention of Sudden infant death syndrome (SIDS)
- Back to sleep: lay the infant on their back on a firm mattress. Turn their head to each side each night to prevent flatten occiput
- Front play: supervised play)
- Don’t share the bed
- Smoking cessation
- Avoid overheating and overdressing
7 y-o patient who has a strike to the side of the head during baseball practice. The patient has loss of consciousness, then seem fine, but then go into a coma.
CT scan shows lens-shaped hematoma
Dx?
Epidural Hematoma
Baby with loss of consciouness after she “fell from her crib” according to her dad.
CT showing crescent-shaped hematoma.
Dx?
Subdural Hematoma
Shaking baby syndrome (abuse)
Patient with deceleration truma.
Ct showing punctate intracerebral hemorrhages
Dx?
Contusion
Prevention of head trauma in children?
Car safety • Car seats (0-2 years) • Booster seat (until 4’9” and 8-12 years old) • Seat belts Helmets: Trampolines: eliminate them
Boy with helmet-to-helmet football injury. LOC < 60 sec, mild headache that is improving, no amnesia. no FND on physical exam.
Dx and next step and follow-up?
Mild concussion
Next step: no CT needed. Discharge and observe
F/U:
Stepwise Return to Play
Sleep–> go to school–> homework–> practice–> play
Boy with helmet-to-helmet football injury. LOC > 60 sec, headache that is worsening, retrograde amnesia. FND on physical exam.
Dx and next step and follow-up?
Severe concussion
Next step: CT and admit
F/U:
Stepwise Return to Play
Sleep–> go to school–> homework–> practice–> play
Prevention of drowning
- Limiting access (gates, fences)
- Supervision
- Flotation: life jackets, not arm floaties
Gun safety in a house with kids
o Get rid of the gun if possible
o Store up high
o Locked in a safe cabinet
o Amo stored separately from gun
Child with mental retardation, son of a single young parent from a low socio-economical background. The child presents to the ER with a femur fracture. In the physical you see brises in different stages of healing. The child does not cry when the parent is present.
Dx and next steps?
Abuse
Next steps:
o Report to Child Protective Services
Certainty is NOT required
Tell the family why you’re doing it (patient safety) and that you’re required by law to do so
o Patient safety
Separate abuser from child if obvious
Separate parent-child unit from a common abuser
Hospitalize child if no safe alternative exists
o Offer resources and support that allows families and care givers to understand disease process, provide emotional economic, and physical support
Fractures associated with abuse
- Skull, clavicle
- Femur, especially spiral
- Rib factures
- Different stages of healing
Bruises associated with abuse
- Different stages of healing
- Weird places
- Subdural hematoma (shaking baby syndrome)
Burns associated with abuse
- Feet, ankles (dunk)
- Buttocks only (dunk)
- Punctate circular burns (cigarette)
Child behaviour associated with abuse
- Not crying in the presence of caregiver
- Running from caregiver
- Receiving comfort from healthcare provider rather than caregiver
Child with slapped-cheek appearance, fever, and rash.
Dx and f/u?
Erythema infectious/ slapped-cheek disease/ fifth disease (parvovirus B19)
F/U:
- Watch out for aplastic crisis (especially if sickle cell disease)
- Separate from their mom if she’s pregnant (risk of hydrops)
Patient who had Cough, coryza (runny nose), conjunctivitis, and Kolpik Spots. Then fever and rash starts on the face and it spreads to the body. The rash spreads and clears from head to toe.
Dx?
Measles
Child with periorbital/postauricular tender lymphadenopathies. Then fever and rash starts on the face and it spreads to the body.
Dx?
Rubella
Child with prodrome of a high fever (>40 C). Then, macular rash that begins on trunk and spreads to the face.
Dx?
Roseola
Child with rash that starts on the trunk and head followed by outward spread to extremities. The vesicles are on an erythematous base and are in different stages (eruption, ulceration, crusting).
Dx?
Chickenpox
Pubertal males with parotid slewing and orchitis.
Dx?
Mumps
Child with vesicles on erythematous base involving hands, feet and mouth.
Dx?
Hand-foot-mouth disease
Baby with bulging fontanelle, irritable, then has a seizure.
Dx, next steps, tx?
Meningitis
Next steps:
Evaluate FAILS (FND, altered mental status, lesion on spine, seizure)
Since FAILS (+)
- Blood Culture –> Abx –> CT scan –> LP
Tx: Vancomycin + cefotaxime + ampicillin + steroids
Patient with itching in webs of hands.
Dx, next step and tx?
Scabies
Next step: scrape the skin to see eggs on a scope
Tx: Cover head-to-toe in permethrin or lindane
Patient with itchy scalp. You see eggs in comb when brushing.
Dx and tx?
Lice
Tx: Permethrin, or malathion
Patient with itchy butt.
Dx, next step and tx?
Pinworm (oxyuriasis)
Next step: Put tape on the butt in the AM to catch some eggs
Tx: Albendazole
Patient with general urticaria (rash), hypotension and Wheezing after exposition to a trigger.
Dx and tx?
Anaphylaxis
Tx:
• Epinephrine 1:1,000 IM
• Diphenhydramine, Cetirizine
• Steroids
Wheal (roncha) and erythema and rash
after exposition to a trigger, but no hypotension.
Dx and tx?
Urticaria
Tx:
• Usually self-limited
• Observe and topical anti-histamine
• Rule-out anaphylaxis
Swelling in airway and wheezing after exposition to a trigger, but no hypotension.
Dx and tx?
Angioedema
Tx:
• Secure the airway
• Diphenhydramine, Cetirizine
• Steroids
Patient with shiners under the eyes, pale, boggy mucosa, polyps.
Dx and tx?
Allergic rhinitis
Tx:
• Intranasal steroids!! (the good answer)
• Avoidance of trigger
Patient with shiners under the eyes, conjunctival injection and chemosis (inflammation).
Dx and tx?
Allergic conjunctivitis
Tx: • Avoidance of trigger • Artificial tears • Mast cell stabilizers in drops • Antihistamines in drops • Oral antihistamines • Leukotriene antagonists
Child with nausea, vomiting and diarrhea. The patient has eczema, atopic dermatitis and asthma
Dx, next step and tx?
Food allergy
Next step: Food trial (take out all potential triggers and introduce them one at a time)
Tx:
• Avoid trigger
• EpiPen
Baby, 6 months of age with failure to thrive despite feeding adequate amount. The parents report feeding intolerance, vomiting and occasional bloody stool.
Dx and tx?
Milk protein allergy
Tx:
• Avoid cow’s milk protein until 2-3 years
• Hydrolyzed formula
Unilateral ear pain relieved with pulling of the pinna, swelling of tympanic membrane, loss of light reflex, bulging erythematous tympanic membrane.
Dx and next step?
Otitis media
Next step: pneumatic insufflation (membrane doesn’t move with air)
1st line tx of otitis media
Amoxicillin
Tx of recurrent otitis media
amoxicillin-clavulanate
Indication for tympanostomy if otitis media
3 recurrences in 6 months or 4 in a year
Patient with ottis media and pen allergy. How to treat?
Pen allergy with no anaphylaxis: cefdinir
Pen allergy with anaphylaxis: azithromycin
Unilateral ear pain which is worse with pulling of the pinna and erythematous canal.
Dx and tx?
Otitis Externa
Resolves spontaneously , but if severe infection: cipro drops + steroid drops
Paitent with otitis media and swelling behind the ear, and anteriorly rotated ear.
Dx, next step and tx?
Mastoiditis
Next step: no images, it’s a clinical dx
Tx: surgical decompression
Congestion, bilateral purulent discharge, painful facial tap.
Dx and tx?
Sinusitis
Tx: supportive
- If fever, duration of > 10 days or worsening; amoxicillin-clavulanic
Centor criteria for pharingituis?
- no Cough +1
- Exudates +1
- Nodes +1
- Temperature +1
- Age <14 -1; >14 +1
Tx:
- < 1: nothing it’s viral
- 2-3: rapid strep test
- > 4: treat with amoxicillin-clavulanic
Homeless with scratching and buzzing in the ear.
Foreign body (insect) in ear
DON’T LIGHT!! Instead use lidocaine to paralyze the insect
Baby cyanotic when eating, pink when crying, or snoring in a child.
Dx, next step and tx?
Choanal Atresia
Next step: failure to pass a catheter or fiber-optic
Tx: surgery
2-y-o patient who had a viral prodrome and now has barking or seal-like cough, inspiratory stridor.
Next step?
Administration of racemic epinephrine
If improvement -> Croup
If not -> Bacterial tracheitis
2-y-o patient who had a viral prodrome and now has barking or seal-like cough, inspiratory stridor. Improvement after the administration of racemic epinephrine.
Dx and tx?
Croup (laryngotracheobronchitis)
Tx:
- Mild: mist (agua nebulizada)
- Moderate: racemic epinephrine, IM steroids, O2
- Severe: Admit
2-y-o patient who had a viral prodrome and now has barking or seal-like cough, inspiratory stridor. The patient doesn’t improve after the administration of racemic epinephrine.
Dx and next step?
Bacterial Tracheitis (superinfection of cropu with staph aureus)
Next step: Tracheal culture (get ENT to do a scope)
5-y-o patient No history of vaccinations, Very toxic, Rapid onset high spiking fever, Tripoding, Drooling , Accessory muscles use, Talking with a hot potato voice.
Dx and next step?
Epiglottitis
Next step: Get endotracheal tube (ET) in the OR
10-y-o patient with toxic appearance , Rapid onset high spiking fever, Drooling, Talking with a hot potato voice, Anterior chain unilateral lymphadenopathy, Tender unilateral neck mass.
Dx, next step and tx?
Retropharyngeal Abscess
Next step: CT scan of neck
Tx: Drainage + Abx
Adolescent talking with a hot potato voice, Sore throat, Drooling, Odynophagia, dysphagia , Uvular deviation.
Dx and tx?
Peritonsillar Abscess
Tx: drainage + IV Abx
3-y-o patient, with sudden onset of dyspnea after parents left unattended. On phsysical: expiratory wheeze.
Dx, next step, tx?
Intrathoracic foreign body
Next step: CxR:
Tx: Bronchoscopy if intrathoracic (call respirology)
3-y-o patient, with sudden onset of dyspnea after parents left unattended. On phsysical: inspiratory stridor.
Dx, next step, tx?
Extra thoracic foreign body
Next step: 2-view CxR
Tx: Laryngoscopy if extrathoracic (call ENT)
Patient with suspiction of foreign boddy in trachea vs esophagus.
2-view CxR showing (+) coin sing in lateral view. (-) coin sing in the AP
Where is the foreign body?
Trachea
Patient with suspiction of foreign boddy in trachea vs esophagus.
2-view CxR showing (-) coin sing in lateral view. (+) coin sing in the AP
Where is the foreign body?
Esophagus
Tx of asthma in kids
- Avoid triggers (pets, carpets)
- Smoking cessation on parents
- Progressive use of SABA + Low-dose ICS + high-dose ICS +LABA + oral steroids
Before adding more meds, make sure they are using the inhalers right.
1-y-o pateitn with Wheezing and Dyspnea.
Dx, tx?
Bronchiolitis
Tx: O2, IVF, observation
F/U: Watch out for respiratory failure and ARDS
Child who is foreign born. With recurrent pulmonary infectious and failure to thrive.
Dx, next step and tx?
Cystic Fibrosis
Next step:
- Screen
- Sweat chloride to confirm( > 40 is confirmatory in infant)
Tx:
- Replacement of pancreatic enzymes
- Replacement of fat-solute vitamins (ADEK)
- Pulmonary toilet
Patient with dx of cystic fibrosis who has now pneumonia. What’s the most common bug to having caused it?
Pseudomonas
Child with fever and one seizure in 24 hrs that lasted < 15 mins with loss of consciousness.
Dx, next step and tx?
Simple febrile seizure
Next step: no imaging needed
Tx:
• BZD to abort active seizure
• Acetaminophen
Patient with fever and several seizures in 24 hrs that lasted > 15 mins with loss of consciousness.
Dx, next step and tx?
Complex febrile seizures
Nex steps:
• EEG
• LP
• MRI
Tx:
• BZD to abort active seizure
• Antiepileptic meds (e.g., Levetiracetam, phenytoin, valproate, lamotrigine)
1-y-o patient with bilateral and symmetrical limb jerking. No fever.
Interictal EEG showing hypsarrhythmia (chaotic and disorganized brain electrical activity with no recognizable pattern)
Dx and tx?
West Syndrome (infantile spams)
Tx: ACTH
2-y-o patient with angiofibroma and ash leaf spots identified under wood’s lamp
Dx and next step?
Tuberous Sclerosis
Next step: CT or MRI showing cortical tubers
Boy who is “troublemaker”, and has bad performance at school.
Next step?
EEG to differentiate between ADHD and absence Seizures
Tx of absence Seizures?
Ethosuximide
Valproic acid as 2nd option
Premature baby with GI bleed. Babygram showing pneumatosis intestinalis (air in the wall of the bowel) or air under the diaphragm.
Dx and tx?
Necrotizing Enterocolitis
Tx:
- NPO
- IVF
- Total parenteral nutrition (TPN)
- Abx against gram negatives and anaerobes
1-y-o patient with abrupt colicky abd pain, knee-chest position relief the pain and Currant jelly diarrhea
On physical you fee a sausage-shaped mass.
Dx. next step and tx?
Intussusception
Net steps:
- KUB to r/o air under de diaphragm
- U/S showing target sig
Tx:
- Air enema
- Surgery if enema fails, peritonitis or perforation
2 yr patient with Painless, intermittent hematochezia, fecal occult blood test (+), and iron deficiency anemia.
Dx, next step and tx?
Meckel’s
Next step: Technetium 99 radionucleotide scan
Tx: Resection
Newborn with melena.
Next step?
Apt test (negative means blood comes from the mother)
Watery diarrhea with weight loss, EGD and colonoscopy showing skipped lesions.
Dx and tx?
Chron’s
Tx: immunomodulation, surgery for fistulas
Bloody diarrhea, colonoscopy showing continuous lesion only in colon.
Dx and tx?
Ulcerative colitis:
Tx: surgery is curative
Patient with history of sickle cell disease who goes to the ER with stroke, acute chest, pulmonary edema, or SOB.
Tx?
EMERGENT exchange transfusion!!!
Chronic consequences of sickle cell disease at the spleen
Auto infraction of the spleen (prone to infection from encapsulated bugs)
- PPx with PNC until age 5
- Pneumococcal vaccine
Chronic consequences of sickle cell disease at the bone
o Osteomyelitis produced by S. Aureus (most common) or Salmonella
o Avascular necrosis of hip (Tx: 1st conservative, then Sx)
Patient with history of sickle cell disease with acute worsening of joint pain
↑Reticulocytes and Bilirrubin (greater than patient’s baseline)
Sickles on smear
Dx and next step?
Vaso-occlusive crisis
Tx: • IVF • O2 • Pain control • Treat infection if present
Patient with history of sickle cell disease with acute worsening of joint pain
Reticulocytes and Bili equal to patient’s baseline
No Sickles on smear
Dx nad next step?
Factitious disorder
Give the patient psychosocial help as s/he is faking it.
How to prevent a patient with sickle cell disease from having Vaso-occlusive crisis?
hydroxyurea (increases production of HgbF–fetal)
1-y-o patient with fixed split S2 on auscultation
Dx, next step and tx?
Atrial septal defect (ASD)
Next step: Echo
Tx: Closure via catheter-directed device closure.
Down’s associated with which cardiac deffects
Tetralogy of Fallot
Ventricular septal defect (VSD)
<1y-o patient with harsh holosystolic murmur
Dx, next step and tx?
Ventricular septal defect (VSD)
Next step: Echo
Tx:
• Asx: wait until 1 yr and see if it’s gone
• If CHF or failure to thrive: surgery
Newborn with continuous machine-like (multiphasic) murmu, which was not present in his first physical exam
Patent ductus arteriosus (PDA)
Next step: Echo
Tx:
• May self-close
• Closure when needed with Indomethacin
Baby cardiac defect associated with history if DM in mom
Transposition of the Great Arteries
Cyanotic newborn. Echo shows Transposition of the Great Arteries. Tx?
- Prostaglandins to keep PDA
* Surgery
Components of Tetralogy of Fallot
o VSD
o Overriding aorta (Dextroposition of aorta)–> Cyanosis
o Pulmonic stenosis
o Right ventricular hypertrophy
Cyanotic child. Cyanosis relieved when squatting.
CxR showing boot-shaped heart
Dx and tx?
Tetralogy of Fallot
Tx: Surgery
HTN/Warm in upper extremities
Hypotension/Cold in lower extremities
Claudication (the child refuses to cry or walk)
Dx, next step and tx?
Coarctation of aorta
Next step: Echo
Tx: Surgery
Newborn with clicking of the hip (Barlow and Ortolani) that persist after 4 weeks.
Dx, next step and tx?
Development dysplasia of the hip (DDH)
Next step: U/S at 4 weeks
Tx: harness
6-y-o patient with insidious onset, knee pain and antalgic gate.
Dx, next step and tx?
Legg-Calve-Perthes (avascular necrosis)
Next step: xR
Tx: Cast
Teenage who is obese with no traumatic joint pain.
Dx, next step and tx?
Slipped capital femoral epiphysis (CFE)
Next step: frog-leg xR
Tx: Surgery
Patient with joint pain, fever, leucocytosis, ↑ESR and CRP, inability to bear weight.
Dx, next step and tx?
Septic Joint
Next step: arthrocentesis with > 50,000 WBC
Tx: Drain and abx
Toddler with hip pain after a viral illness, inability to bear weight, no fever, ESR and CRP are normal
Dx and tx?
Transient Synovitis
Tx: supportive care
Teenage athletes with knee pain on tibial tubercle and tibial swealing.
Dx and tx?
Osteochondrosis (Osgood Schlatters)
Tx:
- Stop exercise is curative
- Continue exercise but a painful palpable nodule will form
Teenage girl whose spine is tilted to the right.
Next step and tx?
Scoliosis
Next step:
- Adam’s test (“touch your toes”)
- xR
Tx:
- Brace
- Surgery
Patient with focal atraumatic bone pain
xR shows sun burst pattern tumor in the distal femur
Dx, next step amd tx?
Osteosarcoma
Next step: MRI. Bx
Tx: resection
Patient with focal atraumatic bone pain
xR shows onion-skin tumor located in the mid-shaft
Dx, next step amd tx?
Ewing’s Sarcoma
Next step: MRI. Bx
Tx: resection
When to perform an open reduction internal fixation to a fracture in a child?
- Open fracture
- Comminute/angular
- Involvement of the growth plate
Child with light reflect in different spots of the eyes.
Dx and tx?
Strabismus
Tx:
- Congenital: surgery before 6 moths
- Acquired: patch the good eye or use glasses
Congenital cataracts at birth associated with?
TORCH
Congenital cataracts not present at birht but then developed are associated with?
galactosemia
You’re doing the first physical exam in a newborn and there is no red reflex, instead, you see a white retina
Dx? Association in teenage years?
Retinoblastoma
Osteosarcoma association during the teenage years
Premature newborn who received high levels of FIO2 used to treat bronchopulmonary dysplasia.
Whar diseases you need to keep an eye for?
Retinopathy of Prematurity, intraventricular hemorrhage, necrotizing enterocolitis
24-hr newborn with Bilateral, non-purulent discharge on eyes. Dx?
Chemical conjunctivitis, highly likely due to silver nitrate that was given as Ppx.
2-days old baby with Bilateral Purulent discharge on eyes.
Dx, next step and tx?
Conjunctivitis (Gonorrhea)
Next step: Get chocolate agar culture and PCR
Tx:Ceftriaxone IM
14-days old baby with discharge on eyes. Initially, it was unilateral and mucoid, but now it is bilateral and purulent.
Dx, next step and tx?
Conjunctivitis (Chlamydia)
Next step: Get culture and PCR. Look for possible pneumonia.
Tx: Oral erythromycin
Kid with microscopic hematuria. Next step?
Might be self-limiting. CT scan if trauma
Kid with macroscopic hematuria. Next step?
Umicro to see the morphology of the RBCs. If dysmorphic or RBC casts, think glomerular disease. If normal morphology and no casts, think no glomerular disease and do a U/S or cystoscopy.
Baby with no urinary output and oligohydramnios.
U/S showing distended bladder and hydronephrosis.
Dx, next step and tx?
Posterior Urethral Valves
Next step: Voiding cystourethrogram (VCUG) to r/o reflux
Tx:
- Catheter
- Surgery
What’s the most important think to keep on mind for hypo/epispadias?
DON’T CIRCUMCISE!! (foreskin is used to reconstruct the urethra)
Teenager who when drinking alcohol has colicky abd pain than then resolves.
U/S showing hydronephrosis without hydroureter
Dx, next step and tx?
Uretropelvic Junction Obstruction
Next step: Voiding cystourethrogram (VCUG) to r/u reflux
Tx: Surgery
Girl with normal bladder function but constant leak and never dry (like they if she had a fistula).
Normal U/S (no hydronephrosis)
Normal Voiding cystourethrogram (VCUG) r/u reflux
Dx and tx?
Ectopic Ureter (AKA low implantation ureter)
Tx surgery
Child with recurrent UTIs and pyelonephritis.
U/S showing hydro
Dx, next step and tx?
Vesicoureteral Reflux
Next step: Voiding cystourethrogram (VCUG) confirming reflux
Tx:
- Abx (if not severe it may resolve)
- Surgery
> 6 months patient with recurrent infections, severe infections with normal bugs, or infection with unusual pathogens.
Next steps?
Immunodeficiency
- CBC + differential
- Quantitative IgA, IgG, IgM
Egg allergy. What vaccines are contraindicated?
- Yellow fever
- Influenza
• Can be given if mild reaction (rash) with 30-min monitoring
• It’s changing and some vaccines are no longer made out of eggs
Immunocompromised or pregnancy. What vaccines are contraindicated?
- MMRV
- Influenza (intranasal)
Mother Hep B (+). How to immunize the baby?
Give Heb B Ig and Heb B vaccine ASAP
Mother with unknown status of Hep B status. How to immunize the baby?
Hep B vaccine ASAP and check mom’s HBsAg. If +, give baby Hep B Ig
Mother Hep B (-). How to immunize the baby?
Heb B vaccine within 2 weeks of age.
Tetanus immunization
DTad 5 doses (3 in 1st year and 2 between 1-4 yrs. Td (booster) or Tdap (adults) q10yrs.
Hib immunization
Vaccine before the age of 2
MMRV immunization
Vaccine and booster before school
Differences of pneumococcal immunization between immunocompromised and asplenic patients, and infants.
23 valent if immunocompromised and asplenic and 13 valent as infant
Meningococcal immunization is required for?
Rerquired for collegue and military
HPV immunization.
All boys and girls aged 9-26 years
Vaccine that is contraindicated if intussusception
Rotavirus (oral)
Patient with clean wound and < 3 tetanus vaccine doses or unknown. Next step?
Clean the wound and give TdaP (“never miss an opportunity to give the TdaP”)
Patient with dirty wound (metal, puncture, rust) and < 3 tetanus vaccine doses or unknown. Next step?
Clean the wound and Give TdaP + TIG (IV-Ig–passive immunity)
Patient with clean wound and > 3 tetanus vaccine doses, the last of which was 10 years ago. Next step?
Clean the wound and TdaP
Patient with clean wound and > 3 tetanus vaccine doses, the last of wish was less than 10 years ago. Next step?
Clean the wound and send them home
Patient with dirty wound (metal, puncture, rust) and > 3 tetanus vaccine doses, the last of wish was 5 years ago. Next step?
Clean the wound and TDaP
Patient with dirty wound (metal, puncture, rust) and > 3 tetanus vaccine doses, the last of which was < 5 years ago. Next step?
Clean the wound and send them home
Child immigrant without immunizations who after flu-like symptoms has cough spells followed by inspiratory woops that sound like wheezing.
Dx and Tx?
Pertussis
Tx: supportive + erythromycin
Child immigrant without immunizations who has fever and pseudomembrane in the back of the throat causing dysphagia and dyspnea.
Dx and tx?
Diphtheria
Tx:
- Secure airway (intubate)
- Anti-toxin + IV Ab
Nontender abdominal mass associated with elevated Vanillylmandelic acid (VMA) and Homovanillic acid (HVA).
Neuroblastoma.
The most common type of tracheoesophageal fi stula (TEF). Diagnosis?
Esophageal atresia with distal TEF (85%). Unable to pass NG tube.
Not contraindications to vaccination.
Mild illness and/or low-grade fever, current antibiotic
therapy, and prematurity.
Tests to rule out shaken baby syndrome.
Ophthalmologic exam, CT, and MRI.
A neonate has meconium ileus.
CF or Hirschsprung’s disease.
Bilious emesis within hours after the first feeding.
Duodenal atresia.
A two-month-old baby presents with nonbilious projectile emesis. What are the appropriate steps in management?
Correct metabolic abnormalities. Then correct pyloric
stenosis with pyloromyotomy.
The most common 1° immunodeficiency.
Selective IgA deficiency.
An infant has a high fever and onset of rash as fever breaks.
What is he at risk for?
Febrile seizures (roseola infantum).
A boy has chronic respiratory infections. Nitroblue tetrazolium test is (+).
What is the immunodeficiency?
Chronic granulomatous disease
A child has eczema, thrombocytopenia, and high levels of IgA.
What is the immunodeficiency?
Wiskott-Aldrich syndrome
A four-month-old boy has life-threatening Pseudomonas infection.
What is the immunodeficiency?
Bruton’s X-linked agammaglobulinemia
Acute-phase treatment for Kawasaki disease.
High-dose aspirin for inflammation and fever; IVIG to prevent coronary artery aneurysms.
Treatment for mild and severe unconjugated hyperbilirubinemia.
Phototherapy (mild) or exchange transfusion (severe).
Sudden onset of mental status changes, emesis, and liver dysfunction after taking aspirin.
Reye’s syndrome.
A child has loss of red light refl ex. Diagnosis?
Suspect retinoblastoma.
Vaccinations at a six-month well-child visit.
HBV, DTaP, Hib, IPV, PCV.
Tanner stage 3 in a six-year-old girl.
Precocious puberty.
Infection of small airways with epidemics in winter and
spring.
RSV bronchiolitis.
Cause of neonatal RDS.
Surfactant deficiency.
A condition associated with red “currant-jelly” stools.
Intussusception.
A congenital heart disease that causes 2° hypertension.
Coarctation of the aorta.
First-line treatment for otitis media.
Amoxicillin × 10 days.
The most common pathogen causing croup.
Parainfluenza virus type 1.
A homeless child is small for his age and has peeling skin and a swollen belly.
Kwashiorkor (protein malnutrition).
Defect in an X-linked syndrome with mental retardation, gout, self-mutilation, and choreoathetosis.
Lesch-Nyhan syndrome (purine salvage problem with
HGPRTase defi ciency).
A newborn girl has a continuous “machinery murmur.”
Patent ductus arteriosus (PDA).
Eisenmenger’s syndrome
Reverse of a L–>R Shunt to R–>L shunt. Occurs later in life reverse of shunt, and has cyanosis (unlike L–>R shunts)
