Peds Flashcards
Duodenal atresia
Failure to reanalyze; polyhydramnios in utero
Bilious vomiting
Double bubble on XR with no distal air
Down Syndrome
Annular pancreas
Double bubble with or without distal air
Bilious vomiting
Malrotation/volvulus
Upper GI series: abrupt cutoff of GI tract
Bilious vomiting
Contrast enema: abnormal position of the cecum
Leads to ischemia
Intestinal atresia
Double bubble with multiple air-fluid levels
Bilious vomiting
Mom had cocaine or tobacco problem
Pyloric stenosis
Sudden onset projectile non-bilious vomiting; olive shaped mass and visible peristaltic waves
CMP: hypochloremic, hypokalemic, metabolic alkalosis
US: donut sign
TE fistula
Non-bilious vomiting
NG tube will coil
Bubbling and gurgling with respirations
Bilirubin metabolism
Unconjugated from heme breakdown (indirect) -> conjugated in the liver (direct; water soluble) -> unconjugated in the colon
Dangerous hyperbilirubinemia
Indirect/unconjugated can cause kernicterus; >20/25
Direct is more concerning: sepsis/obstruction/metabolic dz
Work up for indirect hyperbilirubinemia
Coombs: isoimmunization
Hgb, Retic count
Work up for direct hyperbilirubinemia
HIDA, Hepatic US, sepsis, metabolic eval
Breast feeding jaundice
Quantity problem -> more frequent feeds
Elevated unconjugated
Presents <7 days old; not feeding well, dehydrated, jaundiced
Breast milk jaundice
Quality issue (enzyme problem)
Elevated unconjugated
Presents >7 days old; will be feeding normally (just jaundiced)
Temporarily switch to formula
Gastroschisis vs omphalocele
Gastro: to the right, no membrane, no chromosome abnormalities
Omphalocele: midline, membrane, chromosome abnormalities
Biliary atresia
Persistant/worsening jaundice after 2 weeks; direct hyperbilirubinemia
US + LFTs -> HIDA scan: 5-7 day phenobarbital sim shoes lack of bile reaching duodenum -> intraopertive cholangiogram
Treat w/ Kasai (hepatoportoenterostomy)
NTD
Fusion of caudal neural tube
Elevated AFP
Managing dirty wound
<3 lifetime doses of Tdap: Clean gets tdap/dirty gets tdap + TIG
>3 doses: clean but >10 years tdap, clean <10 home, dirty >5 years tdap, dirty <5 years home
Contraindications to Tdap
Absolute: encephalopathy <7 days after previous dose
Relative: fever, shock, crying, seizures
Epidural hematoma
Temple trauma, lucid interval, “lens” on CT
Evacuate
Subdural hematoma
Trauma/abuse, LOC w/no lucidity, “crescent”
Evacuation and ICP mgmt
Cerebral contusion
Trauma, LOC, punctate hemorrhage
Manage ICP
Car seats
Rear-facing: 0-2y
Booster seat: until child is 4’9 (8-12y)
Parkland formula
%BSA x kg x 4
1/2 in 8 hours, 1/2 in 16
Sx of shaken baby
Subdural hematoma, retinal hemorrhage
Erythema infectiosum
Parvovirus B19, slapped cheek, lacy rash
Aplastic crisis, hydrops
Measles
4 C’s: cough, coryza, conjunctivitis, coplik spots (white centers on bright red buccal mucosa)
Rash starts on face -> body
Fever starts with rash
SSPE is concerning sequelae
Rubella (german measles)
Togavirus
Face -> toes spread; macular (fainter and quicker than measles)
Generalized tender lymphadenopathy
Forchheimer spots (red enanthem)
Roseola
HHV-6
Prodrome of high fever that breaks when rash starts
Macular rash on trunk -> face
Febrile seizures
Varicella
Chicken pox VZV Rash on trunk/head -> outward spread Vesicles on an erythematous base in different stages Contagion ends with final crust
Varicella zoster
Shingles
Immunocompromised adults w/varicella hx
Painful prodrome and rash in dermatomal distribution; does not cross the midline
Posteherpetic neuralgia treated with TCA or gabapentin
Mumps
B/L parotid swelling
Orchitis
HFMD
Coxsackie A
Vague prodrome, often oral pain
Vesicles on erythematous base
Can see herpangina: lesion on soft palate, tonsils, uvula
Bulging fontanelle
Meningitis
HSV encephalitis
Hippocampus
Bloody LP
West Nile
Paralysis + encephalitis
Causes of osteo
Most common: staph
Animal bite: pasturella
Sickle cell: salmonella
Pneumonia
Strep pneumo, H. flu, Moraxella
Neonatal: E. coli, GBS, chlamydia
Allergic rhinitis
IgE
Venous congestion under eyes (allergic shiners), transverse nasal crease (allergic salute), pale and boggy nasal mucosa, polyps, posterior cobblestoning
First line treatment for otitis media
Amoxicillin
Causes of otitis externa
Pseudomonas, S. aureus
Croup
Viral prodrome, barking cough, inspiratory stridor, worse at night
Steeple sign on XR
Recepi and steroids
Epiglottitis
High fever, rapid onset
Tripoding, drooling, thumb print sign on XR
Straight to OR
Bacterial tracheitis
Ill appearing, subglottic narrowing on XR
Presents similar to croup but in older children
Tracheal culture, abx
Retropharyngeal abscess
Drooling and fever; neck in sniffing position, muffled voice, unilateral cervical lymphadenopathy, tonsils with gray exudates
Lateral neck XR: widened paravertebral space
CT scan
Consult surgery
Peritonsillar abscess
Hot potato voice, muffled, drooling, tonsillar bulge that displaces uvula
Polymicrobial
Abx and surgical drainage
Breath sounds heard with extra thoracic obstruction (in a FB aspiration)?
Inspiratory (stridor)
Breath sounds heard with intrathoracic obstruction (in a FB aspiration)?
Expiratory (wheezing)
Most likely place for FB aspiration?
Right mainstream bronchus
Treating pneumonia in kids
Typical: amoxicillin
Atypical: azithromycin
Bronchiolitis
Inflammation of small airways by virus; wheezing caused by sloughed epithelial cells
Treat when: O2 <90%, premature, <3m, cardiopulmonary abnormalities or immunodeficiency
CF
Meconium ileus, failure to thrive, frequent respiratory infections, salty
Infertile males, malnourished, pseudomonas
Need pancreatic supplementation and ADEK
Febrile seizures
Generalized, <15m, single episode in 24 hours, no neuro deficits
No workup needed
West Syndrome
Infantile spasm <1yo with symmetric jerking of head, trunk or extremities with NO fever EEG: hypsarrhythmia Treat with ACTH Associated w/ intellectual disability
Tuberous Sclerosis
Intellectual disability, seizures
Ash leaf spots on Woods lamp, angiofibromas, cortical tubers
NEC
Premature baby and bloody diarrhea
XR: pneumatosis intestinalis
NPO, TPN, IV abx (surgery only if no improvement)
Anal fissure
Tear in anal mucosa; hematochezia
Associated w/ constipation
Possible IBD
Intussusception
Abrupt, colicky abdominal pain; knee to chest
3m-3yo
Sausage shaped mass, currant jelly diarrhea
Air-contrast barium enema; US to monitor resolution
Meckel’s diverticulum
Remnant of omphalomesenteric (vitelline) duct; can contain gastric tissue
FOBT+, anemia, or hematochezia
IBD
Blood diarrhea for either; lasts >6w
Seen at 10-20yo
Infectious colitis
Bloody diarrhea and fever
Don’t treat unless septic, Shigella or immunosuppressed
Mild-protein allergy
Hematochezia and FtT ~6m
Typically outgrown
Apt test
Differentiates swallowed maternal blood from fetal blood
Fetal blood resistant to denaturation -> workup
General features of LtoR shunts
Increased vascular markings on CXR
Ventricular hypertrophy -> pulmonary HTN (eventual reversal); not cyanotic until reversal
ASD
LtoR; fixed wide split S2
VSD
LtoR; harsh holosystolic murmur
Most common congenital heart disease
Repair if: right sided hypertrophy, elevated rt pressures, failure to thrive, heart failure
PDA
LtoR; continuous machine like murmur
Connection between aorta and pulmonary artery
Indomethacin to close; PGA to keep open
General features of RtoL shunts
Cyanotic at birth (the T disease)
Transposition of the great vessels
Most common cyanotic defect of a newborn
Risk factor: pregestational diabetes
Fatal with no PDA
Tetralogy of Fallot
Most common cyanotic defect of children
Overriding aorta, pulmonary stenosis, RVH, VSD
Tet spells (increases vascular resistance), boot shaped heart
Down and DiGeorge
Coarctation of aorta
HTN, claudication, temp difference between arm and legs
Rib notching
Legg-Calve-Perthe Disease
~6y; avascular necrosis of the hip
Insidious onset knee pain, antalgic gait, pain with abduction & internal rotation
Slipped Capital Femoral Epiphysis
Adolescents: obese or growth spurt
Sudden onset of hip or knee pain
Frog leg XR
Septic hip
Any age (typically a toddler) Febrile illness and joint pain XR -> joint aspiration
Transient Synovitis
Synovial inflammation up to 4 weeks after URI or GI viral illness
No fever, no leukocytosis
Osgood-Schlatter Disease
Teenage athlete; painful knee with swelling over tibial tubercle
Stop exercising or play through it; palpable nodule
Osteogenic sarcoma
Sunburst onion skin at the distal femur
Retinoblast
Ewing’s sarcoma
Midshaft; t(11;22) translocation
Strabismus
“Lazy eye”; reflection of light comes from separate locations on each eye
Patching, glasses, surgery
Retinoblastoma
Pure white retina instead of red reflex
Look for osteosarcoma
Cataracts
Milky white
TORCH or galactosemia
Posterior urethral valves
Male; low/no urine output and +/- palpable bladder
Redundant tissue in urethra
Hx of oligohydramnios
VCUG
Ureteropelvic junction obstruction
UPJ narrow -> colicky pain
Dx with US; VCUG for reflux
Ectopic ureter
Females with have constant leak
Vesicoureteral reflux
Retrograde urine flow; UTIs and scarring
Dx with VCUG
Sickle cell substitution
Valine for glutamine at 6th
Baseline labs in sickle cell
Bilirubin, LDH and retic elevated
Haptoglobin low
Sickle cell associations
Pigmented gallstones/early cholecystecomy
Splenic autoinfarct
Osteomylitis (salmonella)
Avascular necrosis
Bruton’s agammaglobulinemia (XLA)
X-linked; b-cell deficiency (humoral)
Recurrent “normal” infections: sinus, ears, pneumonia
All Ig are deficient; flow cytometry: no B cells
BTK gene
Treat with scheduled IVIG
Hyper-IgM
Low IgA and IgG (IgM normal to high); no class-switching
IVIG
Selective IgA deficiency
Most common primary immunodeficiency
Mucosal barriers
Anaphylactic reaction after blood transfusion (to foreign IgA)
Common variable immunodeficiency
Looks like XLA but less severe
Deficient in at least 2 of 3 Ig
Scheduled IVIG
DiGeorge (22q11)
Absent thymus, micrognathia, wide spaced eyes, low set ears
Defect in cellular immunity (thymus); fungal and pneumocystis; watch Ca
TMP/SMX, IVIG and bone marrow transplant
Wiskott-Aldrich
Combined humoral and cellular defect
X-linked
“Normal” infections, thrombocytopenia, eczema, elevated IgE and IgA
IVIG, splenectomy, bone marrow transplant
Ataxia-Telangiectasia
Telangiectasia+ataxia, poor DNA repair, lymphoma and leukemia
Sinopulmonary infections and no IgA
SCID
Causes by absent adenosine deaminase
Essentially AIDS
IVIG and bone marrow transplant
Chronic granulomatous disease
Cant kill catalase +
Chronic skin or organ abscesses
Elevated IgM and IgG, elevated WBC (just not doing shit)
Negative nitro blue test -> no respiratory burst
TMP/SMX and itraconazole, bone marrow transplant
Leukocyte adhesion deficiency
Neutrphils cant get out of blood vessel No pus but massive leukocytosis and fever Seen at body/environment junctions Delayed separation of cord Bone marrow transplant
Chediak-Higashi
Indscriminate lysosomal fusion
Albinism, neuropathy and neutropenia
Giant granules in neutrophils
Infections of mucous membranes and skin
Hyper-IgE (Job) Syndrome
Elevated IgE and peripheral eosinophilia
“Cold” abscesses (staph, h.flu, strep pneumo)
Eczema, retained primary teeth, fractures, post-infection pneumatoceles
C1 esterase deficiency
Herediatry angioedema (defect of C1 inhibitor) Treat with FFP
Gonococcal neonatal conjunctivitis
Swelling, profuse purulent drainage, corneal edema/ulcer
Single IM cephalosporin
Chlamydial neonatal conjunctivitis
Mild swelling, water/serosanguinous/purulent drainage
PO macrolide
Spondylolisthesis in adolescents
Due to growth spurts/ increased lordosis
Pain with extension (athletes with repetitive extension and rotation at higher risk)
Palpable step-off
Diamon-Blackfan anemia
Congenital erythroid aplasia
Craniofacial abnormalities, triphalangeal thumbs, increased risk of malignancy
Macrocytic anemia and reticylocytopenia
Treat with steroids and RBC transfusions
GB
Diagnose clinically: ascending paralysis & decreased reflexes CSF: increased fluid, nml leukocytes Abnml electromyogrpahy Monitor respiratory function IVIG if needed
Treat acute vs chronic ITP
Acute: observe/GC, IVIG or anti-D
Chronic: splenectomy
Kid with undiagnosed CF
Recurrent pulmonary infections
Greasy, loose stools (pancreatic insufficiency)
Bleeding (no ADEK)
ALL
Most common childhood cancer
Lymphadenopathy/hepatosplenomegaly/ pallor/petechia
Lymphoblasts on biopsy
Burkitt lymphoma
B cells, EBV
Mass on mandible or abdomen
“starry sky”
CLL
Lymphadenopathy
Adults
Smudge cells
Hodgkin lymphoma
Germinal center of B cells
Fever, lymphadenopathy, mediastinal mass
Multiple myeloma
Plasma cells
Adults
rouleaux RBCs
Scarlet fever
“strawberry tongue”
Exudative pharyngitis
Sandpaper rash that spares palms and soles
Complications of Kawasaki
Coronary artery aneurysm, MI
*do an echo on everyone
Central precocious puberty
Early 2nd sex (<8 and 9yo) Advanced bone age High basal LH OR low basal, high with GnRH stim Caused by early activation of HPG axis MRI for hypothalamic or pituitary tumor Treat with GnRH therapy
Peripheral precocious puberty
Early 2nd sex (<8 and 9yo)
Advanced bone age
Low basal LH AND low LH with GnRH stim
Caused by gonadal or adrenal release of hormones
Cause of cough in croup
Inflammation -> edema and narrowing of proximal trachea (tracheolaryngitis)
Turner’s associations
Coarctation of aorta, bicuspid aortic valve (eventual insufficiency), horseshoe kidney, streak ovaries (not enough estrogen -> osteoporosis)
Neonatal polycythemia
> 65% hematocrit
Presents: Ruddy skin, hypoglycemia, hyperbilirubinemia, irritable
Hydrate
Todd paralysis
Self-limited, focal after a seizure
Hemiparesis or hemiplegia
Duchenne MD
X-r; onset 2-3yo
Weak, grower, calf pseudohypertrophy
Scoliosis and cardiomyopathy
Becker MD
X-r; onset 5-15yo
Milder than Duchenne
Cardiomyopathy
Myotonic MD
AD CTG expansion of DMPK gene; onset 12-30yo
Facial weakness, hand grip myotonia, dysphagia
Arrhythmias, cataracts, balding, testicular atrophy
Recurrent pulmonary and GI infections; no lymphoid tissue (tonsils/lymph nodes)
XLA (abnormal B cell maturation)
Defect in tyrosine kinase
Severe, recurrent viral, fungal and bacterial infections with failure to thrive
SCID
Adenosine deaminase deficiency (impaired T cells)
Recurrent skin and pulmonary infections
CGD (oxidative burst)
Organisms will be catalase-positive
Eczema, microthrobocytopenia (petechia, purpura, bleeding), recurrent infections
WAS (X-r)
Impaired cytoskeleton changes in leukocytes and platelets
Transient tachypnea of the newborn
Inadequate alveolar clearance, mild pulmonary edema
Starts shortly after birth, resolves by day2
CXR: b/l perihilar linear streaking
Respiratory distress syndrome
Surfactant deficiency: alveolar collapse/atelectasis
Respiratory distress and cyanosis
CXR: diffuse, reticulogranular appearance, low lung volume, air bronchograms
Grunting, nasal flaring, retractions
Persistent pulmonary HTN
Pulmonary vascular resistance -> RtL shunt
Cyanosis
Clear lungs and decreased pulmonary vascularity
Bronchopulmonary dysplasia
Initial RDS with persistent low O2
CXR: hazy with decreased lung volumes
Kawasaki
Fever >5days plus >4 of:
B/l conjunctivitis, mucositis (strawberry tongue), cervical lymphadenopathy, rash (erythematous and polymorphous), erythema/edema of hands and feet
Treat with ASA and IVIG
Congential adrenal hyperplasia
21-hydroxylase deficiency
Decreased 11-deoxycorticosterone (aldosterone precursor): salt wasting (hypotension, hyponatremia, hyperkalemia)
Decreased 11-deoxycortisol (cortisol precursor): hypoglycemia
Increased testosterone: Virilization and ambiguous females
Elevated 17-hydroxyprogesterone is diagnostic
Acute weight loss in children to fluid loss
1 kg acute weight loss = 1L fluid loss
Common comorbid disorders with Tourettes?
OCD and ADHD
NF1
AD
Cafe-au-lait, clustered freckles, Lisch nodules (hamartomas of the iris), neurofibromas, optic gliomas
Osteoid osteoma
Bone forming tumor in adolescent boys
Proximal femur, pain at night, improves with NSAIDs
XR: small, round lucency
Monitor
Hirschsprung
Failure of NCC migration; chronically contracted
Associated with Down
Positive squirt sign
Thiamine deficiency in kids
Beriberi
Cardiomegaly, neuropathy
Ascorbic acid deficiency in kids
Scurvy
Ecchymoses, petechia, bleeding gums, hyperkeratosis, arthralgia, impaired wound healing
Hypervitaminosis A
Anorexia, pruritus, lack of weight gain, irritability, tender swelling of bones, alopecia, fissuring of mouth, hepatomegaly
Neuroblastoma
Neural crest cells
Kids <2, abdominal mass, periorbital ecchymoses, spinal cord compression (dumbbell tumor), opsoclonus-myoclonus
Horner’s syndrome
Small, round blue cells
Eczema herpeticum
HSV1; vesicular rash with “punched-out” erosions and hemorrhagic crusting
Murmur of VSD
Holosystolic at lower left sternal border
Prader-Willi
Paternal deletion
Hypotonic, weak suck, obese, hypogonadism, narrow tea/almond eyes/down turned mouth
Treatment of impetigo
Limited: topical abx (mupirocin)
Extensive: oral (cephalexin, dicloxacillin, clinda)
Painless hematochezia in a kid
Meckel diverticulum
Viteeline duct
T-99m scan
Beckwith-Wiedemann Syndrome
Macrosomia, hemihyperplasia, omphalocele, macroglossia
Heavy menstral bleeding in otherwise normal teenager
vWD
Clinical presentation of H-S purpura
Purpura, arhtritis/arthralgias, abdominal pain/intussusception, Renal disease
Homocystinuria
Looks like Marfans but:
Intellectual disability, CVA/thrombosis, fair complexion, megaloblastic anemia
Laryngomalacia
Inspiratory stridor worse in supine position
Most common cause of stridor in infants
Choanal atresia
Blockage of posterior nasal aperture Cyclic cyanosis (worse during feeding)
Gaucher
Hepatosplenomegaly, FtT, delayed puberty, anemia, bone pain
Congenital VZV
cortical atrophy
Congenital HSV
Temporal lobe hemorrhage
Periventricular calcifications
CMV; saliva
Diffuse parenchymal/intracerebral calcifications
Toxo
Hereditary spherocytosis
Triad: hemolytic anemia, splenomegaly and jaundice
Physiologic jaundice of the newborn
Day 2-4
Indirect hyperbili
Hemolytic disease of the newborn
Within 72hrs
Splenomegaly
ABO incompatibility
Target cells + MCV <65
Thalassemia (decreased globin chains)
