Peds Flashcards
Tourette
Age, Comorbidities, Tx
Age: 6-15
Comorbidities: ADHD, OCD
Tx: CBT (habit reversal therapy)
1st line: Risperidone, Aripiprazole (2nd gen antipsychotic )
Conjunctivitis
Viral vs Bacterial vs Allergic
Sx, Bugs, Drugs
Comp of bacterial
Viral:
- Unilateral and bilateral, last 1-2 weeks, watery mucoid discharge, viral prodrome, sandy/burning eyes
- Bugs: Adenovirus
- Tx: supportive care
Bacterial:
- Unilateral and bilateral, last 1-2 weeks, purulent discharge, unremitting ocular discharge, isolated sx
–CONTAGIOUS D/T LARGE AMOUNT OF VIRUS IN DISCHARGE–
- Bug: Staph Aureus, Strep pneumo, Moraxella, H. Influenza –> Erythromycin ointment or polymyxin-trimethoprim drops
- Bugs: Pseudomonas (contact lens) –> Fluoroquinolone drops
Comp: Keratitis (inflammation of the cornea) –> photophobia, blurry vision, foreign body sensation. Dx: slit lamp exam. Can lead to scarring and blindness if not treated correctly.
Allergic:
- Always b/l, <30min - yearly, watery, ocular itching
- Airborn allergens
- Tx: Antihistamine plus decongestant or mast cell stabilizer drops
Spinal deformity
Kyphosis (2 types),
Scoliosis (red flags, Dx, Tx)
Spina Bifida (path, RF, Sx, Tx)
Kyphosis: forward curvature of convexity of thoracic spine.
- Postural kyphosis: A “hump” that is easily corrected by back extension or lying supine. Convexity is typically 20-40 degrees. Asx
- Structural kyphosis: does not correct. Back pain. Must exclude more serious causes.
Tx with special exercises. Back brace or surgery is used for chronic pain or if convexity >60 degrees.
________________________________________________
Scoliosis:
- Lateral S-shaped curvature
- Red flags: Back pain, neurological sx, Rapid progressing curvature (>10degrees each year), vertebral anomalies)
- Dx:
—– Forward bed test with Scoliometer. If angle >7 degrees –> significant —> Progress to X ray of spine to measure Cobb angle.
- Cobb angle >10 have scoliosis
- Once skeletal maturity is reached, tx is unnecessary.
- Cobb angle 10-less than 40: low/medium risk, observe or used back brace
- Cobb angle >40: surgery
________________________________________________
Spina bifida :
Pathogenesis: failure of Neuro tube to close
RF:
- Prenatal maternal folate deficiency
- Gestational diabetes and maternal obesity
- Maternal fever in the first trimester
- Genetic factors
Sx:
- Motor/sensory dysfunction
- Neurogenic bladder/bowel
- Hydrocephalus
- Scoliosis
Dx:
- Elevated alpha-fetoprotein
- Prenatal ultrasound
Tx:
- Surgical closure
- Clean intermittent catheterization
- Scheduled laxatives/enemas
- Bracing: correction of deformities
Sickle cell
Prevent, Tx ,CI
Acute chest syndrome tx
Aplastic crisis vs hyper-hemolytic crisis
Sickle cell trait
Compensation for chronic anemia with increased erythropoiesis and elevated reticulocyte count.
Prevent: Hydroxyurea
Tx: NSAIDs, oral opiate (oxycodone, hydromorphone) then IV opiate (morphine), Hydration, RBC transfusion
CI: cold compress, codeine and tramadol (<12 d/t risk of respiratory depression and death with rapid metabolism)
Acute chest tx:
Sx: >1 of the following: fever, hypoxemia, CP and respiratory distress
Tx: CTX & Azithromycin
Aplastic crisis:
- sudden cessation of erythropoiesis with very low reticulocyte count. Most commonly caused by Parvovirus B19.
Hyperhemolytic crisis:
- acute, severe anemia and increased reticulocyte count. Unknown etiology.
Sickle cell trait
HbA:HbS ratio 60:40
G6PD (whats happening, Sx, Labs, Dx)
Hereditary spherocytosis (Sx, Labs)
- X linked
- G6PD normally protects RBC from oxidative burst by producing NADPH
Sx: - Neonatal unconjugated hyperbilirubinemia
- Acute hemolytic episode: caused by oxidative stress (fava beans, sulfa drugs), Jaundice, pallor, dark urine, abdominal/back pain
Labs: - Hemolytic anemia
- Bite cells with Heinz bodies
Dx: Low assay for G6PD (can be normal if acutely ill)
____________________________________________
Hereditary spherocytosis - Osmotic fragility
- genetic hemolytic anemia
- Spherocytes of peripheral blood smear
Splenomegaly
Slipped Capital Femoral Epiphysis
Tx
Tx: Surgical pinning
Comp: Delay within >24hrs in unstable SCFE –> avascular necrosis, femoroacetabular impingement, osteoarthritis
Congenital Hypothyroidism
Sx <1 vs after, Tx,Comp
Lack signs initially d/t maternal T4 crossing placenta.
Age < 1month: jaundice, poor feeding, hypothermia
Age 1-4mo: failure to thrive, constipation
Dx: newborn screening, High TSH and low T4
Tx: Start levothyroxine immediately, US of thyroid. Excellent prognosis if started by 2 weeks old
Comp: Permanent neuro defects w/o tx
Minimal change disease
Labs, Dx, Tx, Prognosis, no remission? what to do next
Lab: Low albumin, high cholesterol, proteinuria
Dx: Clinical
Tx: steroids
Prognosis:
- Remission but relapse is common
- Low risk of CKD
- Must monitor for proteinuria
If remission does not occur –> biopsy
Central vs peripheral precocious puberty causes
Non-classical CAH
Idiopathic premature pubarche
Precocious puberty: onset of secondary sex characteristics in boys <9 and girls <8
1. Central precocious puberty:
- Causes: Idiopathic, Early maturation of hypothalamic-pituitary-gonadal axis or pituitary tumor.
- Elevated LH and FSH
- starts with breast and testicular growth
2. Peripheral precocious puberty:
- Excess sex hormone production by adrenal tumor, CAH, exogenous estrogen, gonadal tumors
- Low LH and FSH
- acne and early pubic hair
ADVANCED BONE AGE
- Non-classical CAH: Low 21 hydroxylase –> elevated17 hydroxyprogesterone. Advanced bone age and growth, early pubic hair, acne,
- Idiopathic premature pubarche: isolated pubic hair development.
Androgen Insensitivity
Genotype/Phenotype
Path, Presentation
Genotype: 46XY Phenotype: Female
In development, testes produce Anti-mullerian hormone and testosterone. AMH prevent production of female organs, and nonfunctioning androgen receptors prevent male external genitalia.
Breast development and female external genitalia, absent or minimal axillary or pubic hair, absent uterus, cervix, upper 1/3 vagina, Cryptorchid testes
Preseptal vs Orbital Cellulitis
RF, Micro, Dx, Tx
Preseptal
RF: Sinusitis but most commonly breaks in the skin
Micro: Staph aureus of Strep pyogenes
Tx: oral antibiotics
Orbital:
RF: Sinusitis
Micro: Strep Viridans , Strep pneumo, Strep aures, H influenza
Tx: IV Antibiotics (Ceftriaxon or amp - sulbactam, possible add vanco) + surgery if orbital abscess forms
Dx: CT orbits and sinuses
Septic Arthritis vs Transient synovitis
Reactive Arthritis (Bugs, sx, Dx, Tx)
Septic: caused by bacterial infection –> hip pain, swelling, ill-appearing, febrile, can’t bear weight, decrease ROM, elevated WBC and inflammatory markers.
S aureus, Streptococcus, and Neisseria gonorrhoeae are common causes.
Gonorrhoeae usually causes polyarthralgia, tenosynovitis (eg, hand), dermatitis (eg, pustules).
Dx: Joint aspiration
Tx: drainage and debridement, abx
Can get MRI after debridement to see extent of infection
________________________________________________
Transient: preceding viral illness, age 3-8y/o, well appearing, afebrile, low-grade fever, limp but able to bear weight, restricted ROM, normal WBC and inflammatory markers, small effusion. Can have unilateral pain but b/l effusion.
Tx: supportive, NSAIDs, full recovery in 1-2 weeks
______________________________________________
Reactive arthritis
Bugs: Chlamydia, Salmonella, Shigella, Yersinia, Campylobacter, C Diff
Sx: “Can’t see, can’t pee, can’t bend my knee.”
- Conjunctivitis, anterior uveitis
- Urethritis, cervicitis, prostatitis
- Arthritis of larger joints and axial spine
- Keratoderma blennorrhagicum, circinate balanitis
Dx: aspirationto r/o septic joint, may show sterile synovitis
Tx: treat Chlamydia but other rather bugs are self-limiting. Can give NSAIDs for pain, if ineffective, steroids can be considered
Henoch-Schonlein Purpura vs Hemolytic Uremic Syndrome (HUS)
Sx, Labs, Tx
HSP aka IgA vasculitis
- Deposition of IgA, C3 and fibrin in small vessels
Sx:
- Can be preceded by URI
1. Begin as macules that coalesce into Palpable purpura/petechiae on lower extremities
2. Arthritis/arthralgia,
3. Abd pain/ intussusception
4. Renal disease (similar to IgA nephropathy)
- Can also have scrotal pain/swelling
Labs:
- Normal plt, coags, cr.
- High WBCc, ESR
- Hematuria and possible RBC cast and/or proteinuria
Hemolytic Uremic Syndrome
- Can be preceded by acute bloody diarrhea illness (EHEC or Shigella producing Shiga toxins)
1. Microangiopathic hemolytic anemia
2. thrombocytopenia
3. Acute renal failure
Tx: fluids, electrolyte management, blood transfusion, dialysis
Intussusception
Tx, Comp
Tx:
- Pneumatic (air) enema or hydrostatic (saline or water-soluble contrast) enema
- Surgical intervention for failed enema or signs of peritonitis
- Barium enema is avoided d/t risk of peritonitis and electrolyte abnormalities
Comp: perforation
Constipation
RF: solid food and cows milk, toilet training, school entry
Sx: painful/hard bowel movements, stool withholding, encopresis (passing stool in underwear)
Comp: anal fissures, hemorrhoids, enuresis (bedwetting), UTI
Tx:
1. Increase fiber/water intake, limit cow’s milk, 2. Osmotic laxative like lactulose that cause retention of fluid in gut –> softening of stool
3. Stimulant laxative that increase peristalsis
4. Suppositories/enemas
Enuresis (bed wetting)
Nightime urinary incontinence >5y/o
No prior prolonged period of overnight dryness
Path:
- Delayed maturation of bladder control
- Nocturnal urine output (increased evening fluids, decreased ADH)
- low bladder capacity
RF:
- Family hx
- Boys age 5-8
Cause:
Constipation
Bladder dysfunction
Urinary tract infections
Chronic kidney disease
Diabetes mellitus
Diabetes insipidus
Obstructive sleep apnea
Dx:
- Urinalysis: exclude other causes
- Voiding dairy
Tx:
- Treat comorbid conditions
- Behavior modification (restrict evening fluids) and motivational therapy (reward system)
- Enuresis alarm: sensor in patient’s underwear or bed pad to detects moisture and triggers an auditory or vibratory alarm that wakes the patient –> further bladder emptying
- Desmopressin therapy (high rate of relapse after discontinuation. can cause hyponatremia.
ACNE
Tx line (1-5)
1st: Retinoids (salicylic, azelaic, glycolic acid)
2nd:Benzoyl peroxide
3rd: Topical abx (clindamycin, erythromycin)
4th: Oral abx (docycline, minocycline)
5th: Oral isoretinoin
AOM (Micro, PE, Tx) vs Effusion
Otitia externa (Micro, PE, Tx)
Ear hematoma (RF, Sx, Tx, Comp)
Micro:
- Strep Pneumo
- Nontypeable H. Influenza
- Moraxella
PE:
- fever, ear pain, red/bulging TM
- Otitis-conjuctivitis syndrome can also occur
Tx:
- 1st line - Amoxicillin
- 2nd line - Augmentin
- Penicillin allergy: azithromycin or clindamycin
Ear effusion: fluid behind TM which can persist after treating AOM for up to 3 months
________________________________________________
Otitis externa:
Micro:
- Staph Aureus
- Pseudomonas aeruginosa
- Mild: discomfort, pruritus, canal edema. Tx: topical acidifying solution (acetic acid)
- Moderate: moderate pain, pruritus, partial/complete occlusion from edema. Tx: Topical abx (fluoroquinolone, polymyxin B, Neomycin), wick placement if canal is completely occluded)
Invasive otitis: Broad spectrum systemic abx +/- debridement
________________________________________________
Ear hematoma
RF: contact sports injury
Sx: tender fluctuant blood collection on anterior pinna
Tx: Immediate I&D, pressure dressing, oral abx to cover pseudomonas , daily follow ups for 3-5 days
Comp: Cauliflower ear, bacterial superinfection, reaccumulation of hematoma
ADHD
Tx based on age
<6y/o: Parent-child behavior therapy
> 6 y/o:
- 1st line (stimulant): Methylphenidate and amphetamines
- 2nd line (non-stimulant): Atomoxetine and alpha adrenergic agonist
- Prior to initiation: cardiac hx (patient or family), exam, baseline weight and vital should be obtained.
- Twitching between meds does not require tapering or washout
Nonaccidental trauma
Burn red flags
Burn: Back/butt with uniform erythema and clear line of demarcation. Ascence of splash marks. Sparing flexural creases. Sparing central butt (forced to bottom of tub and cant more/thrash)
Pediatric Traumatic brain injury (PECARN)
high risk features, Dx
High risk features
- AMS (fussy behavior)
- LOC
- Severe mechanism of injury (fall >3ft in <2y/o and >5ft >2 y/o, high impact, MCV)
- Nonfrontal scalp hematoma
- Palpable skull fracture
- Basilar skull fracutres
Dx: CT scan w/o contrast or observation for 4-6hrs in ED.
Acute Rheumatic Fever
Major and minor criteria, Tx
Major criteria:
J- Joint pain (migratory arthritis)
<3 - Carditis
N - Subcutaneous nodules
E- Erythema marginatum
S- Sydenham chorea (emotional lability, decline in school performance, hand movements, facial grimacing, feet jerking, pronator drift present.
Minor criteria: fever, arthralgia, elevated ESR/CRP, prolonged PR interval
2 MAJORS, 1 MAJOR + 2 MINORS, ONLY CARDITIS OR ONLY SYDENHAM
Prevention: Penicillin
Tx: long-acting IM Penicillin until adulthood for secondary prevention to eradicate group A strep and prevent recurrent episodes. Complete resolution occur within months.
Delayed puberty
Constitutional puberty delay
Familial short stature
Boys:
- lack of testicular enlargement by age 14 d/t lack of testosterone
Hypogonadism
- Primary: gonadal failure
- Secondary: impaired GnRH
Work up:
- FSH, LH, Testosterone, Prolactin to differentiate from primary and secondary.
- Bone age radiograph
Girls:
- Lacks breast development by age 12
- Normal order: breast development (thelarche) then onset of menses 2-2.5 years later.
CONSTITUTIONAL PUBERTY DELAY
- Delayed bone age
- Short stature but normal growth velocity
- Family hx of “late bloomers”
FAMILIAL SHORT STATURE
- Normal bone age
- Short stature but normal growth velocity
Cleft lip
Factors
- May occur in isolation, but can be associated with cleft palate.
- The pathophysiology of isolated orofacial clefts is usually multifactorial and related to complex interactions between genetic and environmental factors.
- However, sporadic cases with no family history or identifiable RF can occur.
- Some are related to genetic syndromes with associated multisystem anomalies.
- With the absence of genetic syndromes, the risk of reoccurrence is < 5%.
