Peds Flashcards
Prep for delivery
Towels, warmer, respiratory equipment
GxPy
Gestational age and prenatal care anticipate problems.
Delivery minute 0-1
Stimulate! Overcome primary apnea
-rubbing back with towel or tapping the feet anything tog et first deep breath
O2-spo2 60-65% normal
Help by suctioning mouth first then nose bc mouth breathers
-PPV if not respond
Intubation-stop secondary apnea which is apnea after first breathing episodes, intubation?
HR>100 is goal
If less than 100->PPV probably an oxygen problem
Minute 1-5 after birth
APGAR want 7-10
<7 do something
O2-SPO2 80-85% if need to improve use FIO2%
Do we need to continue PPV or intubation
HR>100
60-100 respiratory problem ->PPV
<60 and good chest movement cardiac initiate cpr with 3:1 and access umbilical vein to give epi
Minute 5-10 after birth
Second APGAR score
Want 7-10
O2 spO2 90-95%
Use fiO2
PPV
HR want >100
60-100 PPV
<60 CPR. Start code 3:1
APGAR
Appearance Pulse Grimace Activity RR
TTN and RDS
TTN-self limiting c-section most often of term near term, grunting (own CPAP, hyperextended lungs on chest x ray…..treat with PPV usually gone 34-48 hours
RDS-not self limiting, developmental, insufficient surfactant . Premature infant, delivered bc or perinatal distress, chest x ray hypoextended lungs with atelectasis, intubation! And maybe surfactant
Hypoglycemia
Worse outcomes for baby and development
Large for gestation age, small for gestational age, IUGR, diabetic mom
Abnormally size,
Pt may be a symptomatic or symptomatic (jittery, tremors, seizures, lethargy)
CX, look for cause of infection could be sepsis….but just fix don’t spend time figuring out
Asymptomatic-feed
Symptomatic-2ml/kg D50-if persistIV D5, 10,10
What do with baby in nursery
- measure weight, length, head circumference
- Cord-2 arteries, 1 vein clamp close to baby
3-shots (vit k (stop hemorrhagic dz and hep b) and drops(erythromycin for eye
4.look fontanella and look for hematoma, red reflex, look for cleft lip palate, feel bones for crepitus (esp clavicle to look for fracture), murmurs, PDA MAY NOT BE AUDIBLE 1ST DAY, lung sounds, assess cord-see bowel problem, genitalia (hypo, epispadias), imperforate anus (clues to VACTRL), skin for jaundice, ortoloni and barlow
Failure to pass meconium vs constipation
FTPM-nothing comes out in 48 hours.
- impoerforate anus
- meconium lieus
- hirschbrungs
Constipation-pooped but not not
- year 2 may also see hirscbrungs
- voluntary holding
- meds, diet, anatomy, neurologic problem
Hirshbrungs-can be at birth or a few years later
Imperforate anus
VACTERL
No hole on new born assessment
Get xray cross table
Mild-ends close to each other and fix now with surgery
Severe-pouch far from anal verge wait for baby to get bigger before surgery, need colostomy now
VACTERL
Vertebra Anus Cardiac Tracheoespohageal fistual Esophageal atresia Renal Limb
US sacrum
X ray anus
Echo
Catheter with x ray(down nostril), x ray wrist, voiding cystourethragram
Do alt his before taker to surgery for imperforate anus if simple fix
Meconium lieu’s
CF
Don’t turn out enough water in lumen meconium plug no stool can move forward
Failure to pass meconium
Had prenatal screen so expect or will have reason without prenatal screen-someone no prenatal care, refugee undocumented worker,
X ray transition point and may show gas filled plug
Water enema treat can be used to diagnose and dissolve plug (gastrograffin)
Sweat chloride test , will need to sup ADEK and give pancreatic enzymes and do pulmonary toilet to prevent respiratory infections
Harsh springs
Failure of migration
Inhibitory neurons that allow relax in Auerbach and Meissen plexus travel across landscape and inner age colon and fails to inner age distal colon
Muscle cant relax stool cant get through
Severity is how proximal
Present-failure to pass meconium in 48 hours, palpable colon, explosive diarrhea on DRE
OR
Chronic diarrhea with overflow incontinence-see as age notice when toilet train
DX x ray good colon is dilated bad colon looks normal. Contrast enema barium
-if diarrhea later present use snore tail mono entry see increased tone.
Best test is biopsy showing no plexus neural surgery are missing
Treat-surgical resection bad colon ..remove part looks normal but biopsy abnormal
Voluntary holding
Pain, embarrassment , cognitive impairment higher risk
Present when toilet training or when going to school
Voluntary may turn involuntary, may have concrete stool and diarrhea can get around. So see overflow incontinence as well here and encopresis
Dx-Clinical
Treat-bowel regimen and behavior tell ok to poop if impacted do disimpaction under anesthesia (not under anesthesia in adult)
Baby Emesis
Normal feeds-non projectile, formula colored and after eating….don’t worry about it
Bilious-projectile, green , distal obstruction to biliary tree(ligament of Treitz), X ray-double bubble+uterine course
—Malrotation-failure of rotation cause obstruction, in normal uterine course(normal pregnancy), no problems with poly hydrmnios, no downs, diagnose X ray, see double bubble, but also see normal gas patten beyond, confirm with upper GI series…is there an obstruction , that with NG tube-decompress
—duodenal atresia-recanulation failure, polyhydramnios, Down syndrome, biliary emesis, x ray shows double bubble, no gas beyond, treat with surgery
—annular pancreas-failure of apoptosis, polyhydramnios, biliary emesis, association with Down’s syndrome, x ray show double bubble, no gas Beyond, treatment is surgery
—intestinal atresia-vascular accidents in utero, mom usually on vasoconstrictor like cocaine, can or cant be polyhydramnios, no association with downs, see x ray with double bubble and multiple air fluid levels, treat with surgery, worried about short gut syndrome, confront mom.
Non-bilious-projectile, not green, higher obstruction
—day 0 TEF-with or without atresia and fistula, nonbiliary emesis, gurgling and bubbling , diagnose with NG tube that could on x ray, treat with Parenteral nutrition to prepare Abby for surgery to reconnect blind pouch
—pyloric stenosis-week 2-8 hypertrophy of pyloric lead to gastric outlet obstruction, male, olive mass, visible peristaltic wave, diagnose with US show donut sign, treat with surgery pyloromyotomy, need CMP-hypochloremia, hypokalemia metabolic acidosis increased CO2, —-correct electrolyte abnormalities before surgery
Jaundice
Bilirubin through the blood stream to the liver. It is conjugate din liver and excreted into the binary tree
-prehepatic, intrahepatic, posthepatic
RBC turns into unconjugated bilirubin
Rate limiting step-UDP gluconoltransferase
Unconjugated in bloom from RBC turnover from hemolysis or hemorrhage
Intrahepatic-mixed,-crigner-nagar, gilbert are uptake and look similar to prehepatic
Dublin Johnson and rotor problem with excretion and look like conjugated
Hepatitis-immune compromised kids and get viral become chronic carrier state, if damage to liver see enzymes rise
Conjugated or direct in kid-biliary atresisa, sepsis, metabolic derangement.
Direct bilirubin conjugated
Good one to have. Has a charge so its water soluble, cant cross cell membranes very well, when excreted in urine trapped and turns the urine dark
Doesn’t cross BBB
Unconjugated bilirubin
Fat soluble Not excreted in urine Does not turn the urine dark Can cross the blood brain barrier Can lead to kernicterus
Physiologic vs pathological jaundice
Physiologic
Onset-after 72 hours, leaves then turns yellow
Resolution <2 weeks
Bili_unconjugated
Rise: not more than 5 points per day
Takes a while to set on, sign its physiologic
Pathological First day Won’t resolve without intervention Usually conjugated bilirubin and rise fast Over 5 points a day.
Treat uncogwith blue light to turn to conj to prevent kernicterus (high Exchange transfusion (really high)
When baby comes in yellow
Look at bilirubin
Conjugated-pathologic jaundice, require work us, US, HIDA scan after phenobarbitals, look for cause of sepsis, metabolic,
Unconjugated-physiologic, where error is coming from, COOMBS test first, if positive, isoimmunization, if negative, look at hemoglobin, if hemoglobin low-hemorrhage cephalohematome, if hemoglobin up-some form of transfusion..twin twin share placenta, delayed clamping, maternal transfusion, if hemoglobin normal check reticulocyte count, if elevated then hemolysis and GCPD defiency, pyruvate kinase defiency, or hemoglobin SS disease, if hemoglobin normal and reticulocyte normal problem with reabsorption breast mild and breast feeding jaundice
Breast mild vs breast feeding jaundice
Both exaggerated physiologic jaundice but need to intervene
Breast feeding-quantity , decrease bowel function, increased reabsorbed, DAY 1-7, unconjugated, just feed baby more
Breast milk-quality issue, milk inhibit is conjugation, unconjugated bilirubin, after day 7, hydrolyzed formula,
Diaphragmatic hernia
Hole in diaphragm allows bowel into chest so get hypoplastic lung
Present-scaphoid abdomen and bowel in the chest
More on left and posteroir
Diagnosis-x ray
Treat surgical repair and give corticosteroids to help develop the lung
Gastroschesis/omphalocele/extrophy of bladder
Gastroschesis
- defect of bowel off to the right side and is angry
- Clinical diagnosis
- treat silo
Omphalocele
- midline and not that ugly/contained
- Clinical diagnosis
- treat with silo
Extrophy of bladder
- mildline but other clue like wet with urine, shiny and red, no bowel (sac of water).
- Clinical diagnosis
- surgical repair
Biliary atresia
Worsening jaundice 7-14 days
Hyperbolic
Diagnose US
HIDA 7 days after phenobarbital
Treat respect
Cleft lip cleft palate
Failure to grow failure to fuse
Soft, hard, or lip itself
Superficial to deep
Cosmetic. , or cant latch, failure to thrive
Diagnosis-cleft
Treat-treat 11-12 months palate then
NTF
Genetic folate defiency, caudal spine fails to form,
Pt-prenatal are, quad screen shows elevated AFP, US show dz, ,
No prenatal care-tuft of hair, meningomyelocele
Occult’s, meningococcal, meningomyelocele
Prenatal dz
Surgical
Arnold chairi malformation II
Hydrocephalus-can lead to developmental delay
Focal neurologic deficit below the level of the lesion
Well visit
Vaccinations
Growing
- failure to thrive so get head circumference, height, weight. In failure to thrive fall off growth chart. Loss of weight first, then height, then head circumference
- organic (genetic, heart dz, pyloric stenosis or GERD)
- non organiz(formula, feed, frequency)
Abuse/neglect
-injuries in infant, suspicious shape, fractures…subclavicular and femur fracture.
Safety-smoking cessation’s, seat belts, car seats. , drowning pool, trampoline
Development-
Developmental milestones
Study it
Egg allergy
Can’t get vaccine made with egg
Yellow fever don’t give
MMRV can give
Flu can give
Immunocompromised
Not live attenuated-aids, transplant, on biological, pregnant
MMRV, flu Intranasal
Normal reaction to vaccine
Temperature <104
Erythema
Consolable
Bad
- tempover 104, anaphylaxis, onconlable
- this is contraindication to get this particular vaccine in future not all vaccines
Contraindications vaccine
Sick? No give it
Family history? No give it
Personal history of reaction, allergy, immunocompromised
Hep b mom
+ Hep b ig and hep b vaccine now
- hep b within 2 months
? Hep b now check moms hbsAG
DTap
Kids 5 doss as kid
3 in 1st year and 2 between 1-4
TD booster every 10 or five years
Tdap is for adults
Hib
No immunity if infected so having it doesn’t help in those less than 2, doesn’t cover non typeable, causes epiglottis and meningitis
MMRV
Vaccine and booster before school
Liver though
Pneumococcal
13 as infant, add 23 is + risk factors to all immunocompromised and asplenic patients
Meningococcal
Everyone vs meningitis
Everyone going into into shared
HPV
9-26
Hep a/b
2 doses for a
3 doses for b -pick up where left off
Flu
Everyone every year
DTap Tdap
Kids DTAP x5
Tdap adults at least once over 11
PREG give em
TD is a booster can be given instead of Tdap
Diphtheria, tetanus, pertussis
Tetanus
Dirty wound, metal puncture rust
Lock jaw and spastic paralysis every muscle will contract cant breath and will die
Diagnosis: clinical
Treatment: INTUBATE and sedate , muscle relaxers and paralytic. IV antibiotics (metronidazole)
How prevent? Tdap adult, Td booster, tetanus IG-IVIG
Every ten years at least three as an adult, wound will be based on lifetime doses and when
Managing A wound with <3 lifetime doses or unknown
Clean wound-Tdap,
Dirty-Tdap and TIG
timing doesn’t matter if <3 lifetime doses
Managing tetanus wound with > or equal to 3 lifetime doses
Clean->10 yr Tdap, <10 yr home
Dirty >5 yr Tdap, <5 yr home
No TIG needed if > or equal 3 lifetime doses
Dirty wounds
Consider 5 yrs and 2 doses-TIG and Tdap vs TDap
Clean wounds
10 yrs and 3 doses TDap vs home
Diptheria
Back of throat, fever and dysphagia, dyspnea from pseudo membrane when open their mouth, DO NOT PEEL will bleed and die
Diagnosis clinical
Treat with intubation and antitoxin with IV antibiotics
Pertussis
3 phases
Catarrhal infectious phase with nonspecific syndrome looks like cold
Paroxysmal phase coughs followed by large inspirations efforts sound like wheezing
Resolution-
Diagnosis clinical
Treat supportive and erythromycin
HPV
9-26 everyone
Varicella
No pox parties
Shingles
Rotavirus
Oral vaccine contraindicated in intussuption
Epidural
Subdural
Contusion
Epidural-strike to head in ball sports and skiing, walk talk and die (loss of consciousness wake up fine but hematoma expands into comma and die)
CT-lens shaped hematoma
Subdural-sig trauma like ped struck, MVA, shaken baby syndrome, abuse
Coma-then stay in coma
CT-crescent shaped hematoma
In under 3 probably abuse, teen probably not
Contusion-deceleration injury ends up with loss of consciousness SPOTS. Move forward and stop . Head hits front of skull then back. Loss of consciousness
CT punctuate hemorrhages
Prevent head trauma
Car safety-rear facing 0-2 booster four foot nine, seatbelt everyone
, helmets, trampolines (no)
Concussion
Head trauma and no bleed
Sports injury
Grade mild vs severe Focal neurologic deficit-not in mild Loss of con-mild less 60 sec HA-not in mild Amenesia-not in mild
Severe-FND, greater 60, worsening HA , retrograde or anterograde amnesia
Mild-go home
Severe-CT scan rule out brain bleed, if negative still going to admit bc concern for neuro checks
Mild and severe allow to return to play in stepwise fashion …brain intellectual first then scrimmage ten play. Anytime symptoms step back and start over
Drowning
Poor swimmer, too young, too drunk
1tsp of water can cause drown
Kids babies at risk
Adolescents drunk and dive into water tubs, pools and buckets
Fences, gates, supervision lifeguards , flotation -floaters are bad don’t help head need life jackets , salt water worse bc pulmonary edema, cold water better bc metabolic demand decreases,
Burns
Parkland formula
50% fluid in first 8 hours
50% given next 16
%body surface area x4 XII body weight only for second or third
Kids heads are bigger-front and back head 9 each, front back chest 9 each, front back abdomen 9 each, arms front and back combined 9, left right front back of legs 9,9,9 1% genitalia
Gun safety
Eliminate guns from home , high up and lock , keep gun separate from amo
Otitis media
URI, bugs , middle ear, tympanic membrane
Unilateral ear pain relieved with pulling of the pinna
Loss of light reflex, bulging erythematoustympanic membrane, fluid behind the ear, but not diagnostic
Diagnosis-clinically with pneumatic insulfation-while looking in ear puff some air and tympanic membrane stays rigid
Treat-amoxicillin , recur add clavulanate, if recur and recur eat tubes tympanoplastis (3 in 6 months or 4 in a year)
Penicillin allergy and non life treating can use cephalosporin like cefdanir, but if had anaphylaxis use a Zithromax in
Otitis externa
Pinna and canal outer ear
Swimmers ear but no dry get pseudomonas
Digital trauma from picking whic leads to staph
Complain unilateral ear pain, WORSE PAIN WITH PULLING EAR
See outer ear canal erythematous and angry
Diagnose CIX
Treat antibiotic drops cipro and steroid drops
Keep an eye out for mastoiditis caused by same bugs especially if have ear tubes…look like acute OM and have mastoid swelling..swelling behind the ear and anterior rotated ear…clinical diagnosis and CT scan can show…treat with surgical decompression
Sinusitis
URI bugs, usually strep
Present with congestion
Bl pure lent discharge thick white and smells
Facial tap produce pain
Don’t do X-ray or ct if get. XRay see air fluid levels and CT’s how opacification, treat supportive unless obvious that viral then wait
Temp >38, greater than ten days, worsening OR OR give them PENICILLIN amoxicillin clavulanate
Cold nasal viral
Rhinovirus, spread by air droplets
Congested, bl clear rhinorrhea, copious
Don’t do x ray or ct. don’t do PCR or tf, don’t do culture, if bl copious non toxic lots of rhinorrhea
Supportive treatment
CT for cold or sinusitis
If recurrent try to find an atomic defect that limits drainage
Consider a foreign body
Pharyngitis
Viral or strep a
Impetigo and pharyngitis-treat pharyngitis to reduce
Present with sore throat and odonophagya Centar criteria -C no cough Exydates Nodes Tempo greater than equal thirty eight C Older 44 minus 1 less than fourteen plus one
Each one step
Less than equal one its viral do nothing
-3 do rapid strep
—if negative but thing so do culture
If greater than equal to four treat antibiotics
Treat amoxicillin clavulanate
If sore throat and big spleen probably mono and do mono spot
Croup
Para influenza
Kids three months to three years
Viral prodrome progress into barking seal like cough in between coughs is strider inspiratory wheeze
X ray se steeple sign subglottix narrowing but not sensitive or specific DONT GET
Clinical better in cold air. Give them racemic epinephrine and get improvement is how diagnose
Treat
Mild-misting
Moderate-treat with racemic epi, steroids, and oxygen
Severe0admit for ongoing oxygen and racemic epinephrine
Bacteria trachitis
Infectious of staph aureus
Viral prodrome four years usually
See croup that does not improve
Seal like barking so give racemic steroids and not better
May have more toxicity higher fever and leukocytes is
X ray see steeple sign so don’t do it
Not better after racemic epi so maybe bracterial
Diagnose with tracheal culture
Treat IV antibiotics , scope
Epidlottis
Fatal
H influenza
Don’t get anymore bc vaccine
3-7 yrs
Sick , rapid onset, high spiking fever, Tripod, drool, accessory muscle use, talk with hot potato or muffled voice
Epiglottis swollen trying to keep neck open drool
X ray see thumbprint don’t waste time with it though
If see clinical and not vaccinated
Treat in OR see cherry reg epiglottis while do endotracheal tube. ALWAYS in or don’t waste time then IV antibiotics
Retropharyngeal abscess
Caused by oral flora
Pt sick, abrupt onset, high spiking fever, drooling, neck extended, neck stiffness, hot potato or muffled voice.
Look for anterior chain unilateral LAD and tender mass
Get CT scan and do IND, aspiration and IV antibiotics
Peritosillar abscess
Oral flora
Pt older over ten years
Hot potato or muffled voice. Drooling, dysphagia odynophagia, uvula deviation see tonsils shift.
Clinical diagnosis
IND and IV antibiotics
Foreign body airway obstruction
Foreign body less than 2 unattended sudden onset SOB
Extrathoracic(oropharynx when inhale inspiratory stridor ENT) vs intrathroacic(expiratory wheeze and call pulm)
Two view x ray look for coin sign. In AP view and lateral
Trachea negative on AP but positive on lateral
If positive AP esophagus
Treat go in and get it 0broncoscopy endoscope if in lung, laryngoscopes if ent, endoscope if GI
Asthma
Obstructive reversible with bronchodilators and induce blue in response to trigger antigen
Usually not in exacerbation but , complain or wheezing and dyspnea of attacks Allergies Atopy Asthma Eosinophilia Immune related things
Diagnose PFT can be reversed wiht bronchodilators or induced with methacoline and watch FEV1q
Treat
Avoid triggers no pets, carpets, pillows, smoking cessation of parents
If asthma not controlled watch use inhaled then add
Bronchiolitis
Virus RSV
Young less than 2
Wheezing dyspnea but in winter
Rule out asthma12-
diagnose clinically don’t do tests
Treat with O2 and IV fluids, symptoms pear day3-4
Support. AHRF, ARDS
Cystic fibrosis
AR CFTR
Diagnosed with prenatal screen Meconium Ileus Recurrent pulm infections Failure to thrive Salty baby
Sweat >40 infant
>60 older
Treat lung-pseudomonas but staph aureus also
Pancreas-replace pancreatic enzymes and give ADEK
Die 45 short stature bc failure to thrive and counsel on genetics likely to be infertile
Sickle cell dz chronic
Alpha2beta2
HBS B2 can get sickle cells
Alpha 2 delta 2 embryonic
Alpha 2 gamma 2 HBF
Sickle cells sickle unde rlow oxygen cant deform like normal cell to fit into capillaries
Hemolysis causes unconjugated bilirubin then conj then into stool…increased RBC turnover increase unconjugated bilirubin so always have a little jaundice bili always between 1-2 as apposed to less than 1 like everyone else so set up for pigmented gallstones!!!!!!!pigmented gallstones may get cholecystetomy
Anemia-baseline anemia and elevated bili so get baseline for acute crisis . Get Hbg 7-8and bili
Kidney make EPO to try to tell bone marrow to re\v up production of RBC so also get baseline reticulocyte
Folate and iron , get transfused and may need defferoximine to in due the iron so no no hyper iron from transfusions don’t want iron overload
Ischemia-acute and chronic. Spleen auto infarct asplenic vaccinate and give prophylactic penicillin until age 5.
Ischemia bone can get osteomyelitis salmonella its sickle but if most common its aureus (but most common staph)
A vascular necrosis of the hip-conservative management for 4-6 months crutches and NSAIDs so if no help go to surgery s
Sickle cell acute
Stroke
acute chest-pulmonary edema SOB
Both get exchange transfusion.
Priapism-drainage first then exchange transfusion
Presence of ss
Hgb
Pain
Bili up
Reticulocyte up
Prenatal screen usually
CBC with sickle cells confirm with hemoglobin electrophoresis and give variant
Acute-vasoocclusiove, worsening of pain,
Vasoocclusive-IVF, O2 and pain control, prevent with hydroxyurea which increase HBF which cant sickle
And is need
Follow up with psychosocial stressors-
Electrophoresis
SS
SC-not sickle cell, low hemoglobin not crisis really
S-trait but council about kids
SBpos-mild
SB0 worst form
Bronchopulmonary dysplasia rds
Decreased surfactant less alveoli
Lungs underdeveloped can’t expandnalveoli can’t get oxygen into blood and get scarring
Premature increased oxygen demands
Increase fio2 for greater than 28 daysand wannanperform lung protective strategy
Xray densities
Treat with surfactant
Mom glucocorticoids
Retinopathy of prematurity from neoangiogrnesis worsened by increased fio2 requirements
Every baby get eye exam if see blood vessels treat laser ablation to rescue the eye
Interventricular hemorrhage -image ,Nd later will see bulging fontanelles think about interventricular if premature diagnose with cranial Doppler , shunts and drains
Nec-x ray air in wall bowel pneunitis intestinaalis
Npo and IV antibiotics, tpn
Surgery
Alte brue
Alte-concerned parent freaks out bc change in color, tone, or breathing of infant.
History and PE \50% time nothing
To GERD, lower airway infection, seizure(limb jerking abnormal eye movements), sepsis (fever, hypothermia),, heart disease(failure to thrive, difficulty eating), abuse(multiple injuries)
Got rid of alte
BRUE-brief resolved unexplained event
-must be infant less than 1, must be less than 1 minute, change in color tone breathing or reponsiveness.
Low risk brue-no history of PE worrisome for cyanosis, murmur fever or abuse, no CPR required and has to be first time.term greater 60 ok, premature over 32 weeks GA, >45 PC
High risk brue-monitor investigate but no specific recommendations
SIDS-no correlation between alte brue and SIDS!
Child dies for no reason diagnosis after autopsy is done
Prevention-1. Back to sleep lay on back so cant roll over and suffocate-flatten occiput turn did side each night
- Don’t share a bed baby with adult
- Smoking cessation.
Don’t do ekg, pulse oxumetry, apnea monitors, don’t do anything to investigate, premature and congenital defect higher risk
Child abuse
Abuse positive symptoms, intentional active harm
Neglect negative what should be doing but aren’t , not intentional always
Erythema infectiousion
5th disease parvo b19, slapped cheek, fever and rash occur at same time Cheeks mainly Virus Diagnose clinical Treatment supportive
Aplastic crisis if sickle cell of hgb problem
Hydrops fetalis -if pregnant with another kid separate baby from mom
Measles
Parvomyxovirus
Prodrome Cough, coryza, conjunctivitis, koplik spot in mouth little white dots
then fever and rash simultaneously
Begin on face and spread down the trunk and arms
Will also clear same way
Diagnose clinically
Treatment supportive
Vaccine MMRV
Subacute sclerosis’s pan encephalitis-MEASLEs
Rubella German measles
Fever and rash but rubella caused by rubella and prodrome is generalized and tender LAD
Start face spread to trunk.. look for swollen tender lymph nodes
FEVER AND RASH
Diagnose clinically
Treat supportive
MMRV
Roseola
HHV6
Prodrome high spiking fever get to over 104 bad over after fever breaks
Fever and then rash
Start on trunk and expands outward to face and extremities
Diagnose clinically
Treat supportive , but be aware of febrile seizures which abort with benzo if last more than 5 minutes
Acetaminophen for high fever not aspirin bc Reyes
Varicella zoster
In adult shingles
In baby chicken pox
Rash without fever diffuse vesicles on erythematous base and in different stages of healing erruptions ulceration then crusting
Clinical diagnosis diagnose by looking
Treat supportive and MMRV vaccine to prevent.
Shingles
In Derm atom always distribution of dorsal root ganglion. If immunocompromised old over 60 and get reactivation
Painful prodrome and vesicular rash in Derm atoms and never crosses midline ….vesicles and not cross midline
Diagnose clinical
Treat acyclovir to reduce duration
Shingles vaccine over 60 reduce chance of shingles
Mumps
Mumps virus
Pubertal males with parotid swelling and orchitis
Diagnosis clinical
Treat supportive
Should have had MMRV
Males orchitis may lead to infertility
Good reason why hasn’t been vaccination
HFMD
Cocksackie a virus
Varicella except only hands foot and mouth/face
Clinical diagnosis
Treat supportive
No vaccine
Meningitis
FAILS-increased intracranial pressure may not be safe for puncture to do CT scan first but if do CT blood cultures, CT, LP if fails
Fails negative LP and antibiotics
Fontanelles bulging =increased intracranial pressure
Adult-vancomycin ceftriaxone and steroids
Pedes-vancomycin, steroids, ampicillin for lsiteria and cefotaxime (ceftriaxone cause hyperbili in less than 30 days)
HIV/AIDS
How baby get-vertical transmission, give azt to mom
<18 months want to know if HIV positive cant use elisa bc antibodies may be moms. Go straight to DNA PCR!!!!!
Haart for any HIV positive
Prophylaxis start
200 PCP trimethoprim sulfa if no use dapsone if no use utovoquone
100 toxo TMP SMX< if no use atovoquone
50 MAC azithromycin
Osteomyelitis
Staph aureus
But if see salmonella think sickle cell
If toxic then give antibiotics before biopsy
Not toxic don’t give antibiotics until gotten biopsy
Get x ray-if positive for osteo go to biopsy
If negative get MRI if that’s positive biopsy
Bone scan-has false positives
Septic joint
Gonorrhea-sex active
Staph stab wounds
Tap joint with arthrocentesis >50,000 WBC start antibiotics
Scabies
Itchy fingers in webs of hands
Scraping see scaby babies
Poop itches
Permethrim lindane
Lice
Itchy scalp spread in share hat or cones
Bugs are big see nits
Further away nit is longer had
Use permethrin
Pinworm
Itchy butt, baby has a worm comes out to lay eggs reintroduces worms
Tape test albendazole
PNA and Tb
<5 viral
Ignore BCG and interprets same
<5 get PPD skin test
>5 use interferon gamma release assay
Treat T with RIPE for full blown
Isoniazid and B6 for latent
Tb ppd
15-people who is everyone
10-homes less prinson healthcare workers ppl should be testing
5 Immunosuppressed and close contacts
Acute allergies
IgE trigger release histamine type I hypersensitivity reactions
Anaphylaxis-urticaria (rash), clear having response, hypotension!, that person is anaphylactic, wheezing and loss of airway, clinical diagnosis, epinephrine 1:1000 IM, don’t wait for IV, reverse hypotension, H1 and H2 blockers, steroids,
Urticaria-rash wheal welt or erythema, no hypotension, clinical diagnosis, self limiting, observe of use topical antihistamines
Bee sting-if anaphylaxis treat like it, if not remove pincer get better
Angioedema-swelling not wheal almost always with ACE inhibitor swelling airways /stridor inspiratory wheezing, usually swelling in one spot no hypotension, diagnosis clinical and treatment is to secure airway, give H1 and H2 blockers and give steroids
Chronic allergies
Allergic rhinitis-seasonal or perineal(all time smoking dust mites pets)
Shiners(bags under eyes), salute nose line , pale boggy mucosa, polyps with cobblestoning pushing to allergic rhinitis
Diagnose-clinically don’t do RAST or skin testing only do RAST of skin when refractory to treatment .
Treat-avoid triggers, true of all allergies,intranasal steroids*
Allergic conjunctivitis -seasonal or perineal, same treatment , same diagnosis, but see shinersinjection, swelling chemosis
Food allergies
Wheat, soy, milk, eggs usually outgrow
Introduce too soon take away and does fine
Nuts and shell fish may cause anaphylaxis
Present N/V diarrhea Allergies Atopy Asthma Look for kids who have eczema or asthma,
Can cause anaphylaxis
-epi
Avoid triggers
Elimination trial
Milk protein allergies
Soy N/V diarrhea Failure to thrive Kid no grow bc eating soy formula Clinical diagnosis Treat change formula -cows milk breast feed of hydrolyzed formula
Seizures
Synchronous firing of awake brain
Complex loss of consciousness
Simple no loss
Generalized-whole brain
Focal=partial
Grand man-gen comp
Partial complex
Particle simple
Generalized simple-pseudoseizure
Seizure-1 time
Epilepsy-recurrent
Eeg-abnormal only when having a seizure
Treat epilepsy-kids=adults
—levetiracetam expensive but most common, phenytoin, valproate, lemotrigine
Absence seizure
Ethosuximide
Tic de la rue trigeminal neuralgia seizure
Carbamazepine
Seizure 1 time`
Vitamins
Febrile seizures
Fevers reduce seizure threshold
Rate vs height
Fever and seizure
Simple- 1 in 24 hours no recur, less than 15 minutes, must be generalized
Benzo if actively seizing
Give antipyretics acetaminophen never aspirin
Ni imaging, no anti epileptic drugs
Complex- Benzo if actively seizing EEG? If not sure if seizure LP? If bulging fontanelles rash all over MRI? If not other 2 Imaging and put on antiepileptic drugs
Infantile spasms-west syndrome
<1 year Symmetrical bl limb jerking Not generalized No fever Just spasms
Diagnose-EEG intercostal EEG show hypsarhythmia
Treat-acth
Can be part of tuberoussclerosis
-genetic disease
<2 yo see angiofibromas ash leaf spots and get brain imaging , afebrile seizures, complex febrile
Diagnosis-neuroimagine see tubers
Treat-supportive die young and have cognitive delay
Absence seizures
100s-1000s of seizures a day
LOC
No loss of tone
Generalized
No postictal state
Kid who has adhd
EEG-
Treat ethosuximide and valproic acid
Most outgrow these
Necrotizing enterocolitis
In NICU premature baby
gi bleed
Diagnose x ray see pneumoatosis intestinalis air in wall of bowel
Treat-NPO, IV fluids, TPN, IV antibiotics after gram - and anaerobes
Anal fissure
Tear anal mucosa in adult
Neonate-iatrogenic bc dont hole poo in
See on visual inspection
Diagnose clinically
Treatment is reassurance
Intussception
Telescoping of bowel into itself that leads to vascular compromise
Vascular supply compromise bowel may die
Patient present with abrupt sudden onset colicky abdominal pain and in child know that knee chest position brings relief
If wait long enough what see is bowel die stuff off and become bloody bowel movement
Red current jelly diarrhea -anything that kills bowel cause this
PE-sausage shaped mass in RUQ usually
Toddlers 3 months to 3 years
Diagnosis first test KUB upright look for perforation and obstruction and free air
Air enema diagnosis also therapeutic
US-very sensitive can track resolution target sign
Treat-air enema
, if not surgery-if frank peritonitis, perforation, failure of air enema
Meckels diverticulum
Truediverticulum remnant of vitaline duct consists of gastric contents can secrete acid so can bleed and ulcerated
Present with painless intermittent hematochezia bright red poo
Toddler
2 less than 2 Less than 2% 2 times in males Usually 2 feet from ileocecal valves 2 inches
Iron def anemia FOBT greater 50 colon cancer keep in mind
Diagnosis-technetium 99 scan
Treat resection
If teenager trying to diagnose CT scan better than bleeding scan
Distractors
Birth-babies can swallow moms blood -apt test
Kids swallow own blood with bloody nose. Lean forward and apply pressure but kids lean back so have blood in mouth
Iron supplementation
Beets
Meds
Inflammatory bowel disease
Crohn-watery diarrhea weight loss
Upper and lower endo and see skip lesions
Anti immune
Surgery if fistula
UC-bloody diarrhea,
Colonoscopy show continuous lesion
Surgery curative -not recur once cut out
8 yrs from diagnosis do every year colonoscopy until hemicolectomy
Infectious colitis
If have fever and bloody bowel movements think about invasive organisms dont treat unless have organism of expect shigella(raw meat)
Get stool cultures generally point in a direction
Milk protein allergy
Change to hydrolyzed formula and see resolution of GI bleed
Developmental dysplasia of dip
Newborn
Ortolani and Barlow click can be laxity so check in 4 weeks if click still there
US 4 weeks
Treatment-harness to line up joint and bones
Leg calves perthes
6 years
Insidious onset of antalgic gait
X ray diagnosis
Treat cast
Slipped capital femoral epithelial
Growth spurt or really fat 13 yo Non traumatic joint pain Frog leg x ray Surgery only one need surgery
Septic joint
Any age child
Arthrocentesis
Show greater than 50,000 white cells-drain and antibiotics
Obvious they will be toxic have fever leukocytosis, ESR and CRP and cant bear weight COCKER CRITERIA
Transient synovitis
Any age Presents with hip pain After viral illness Not reactive See inability to bear weight maybe
Clinical diagnosis and supportive care (anti inflammatory)
Do i need to tap? Cocker if actively infected fever just support
Osgood schlatter/osteochondrosis
Teen athletes Knee pain Tibial swelling Pinpoint tenderness on tibia Diagnose clinical
Treat-sit out of sports rest or work through it have palpable nodule on tibia for rest of life both end up ok
Scoliosis
Deformity of the spine Teen girl Usually side end to right Moderate-cosmetic Severe-tilted far enough may have dyspnea
Adams test-bend over one shoulder higher than other positive
X-ray
Treat-brace can slow progression and escape surgery
Surgery rod reverse in severe or not ant crooked
Ewing
11 22
In mid shaft X-ray onion skin
Osteosarcoma
Retinoblastoma look for sunburst pattern x ray distal femur
Both cancer bone
Focal atraumatic bone pain
Onion skin or sunburst pattern
X ray mri and biopsy
Treatment for both is resection.
Fractures
Kid-
Surgery-open reduction and internal fixation if open fracture, cant line up ends well, or of growth plate involvement
If all negative cast
Amnlyopia
Cortical blindness
From stabismus or congenital cataracts
Happens only during development of brain
Once done it’s done
Clinical diagnosis
No treat
Prevent by correcting underlying illness and dont let it happen
Stabismus-lazy eye shining light on eyelazy eye looking to the side.
Diagnose clinical, fix surgery by six months if congenital, acquired patch good eye and let bad eye catch up or get kid glasses
Cataracts congenital-if baby born with them was torch infection, if develop its inborn error of metabolism like galactose is
Cloudy milky white in front of the eye.
Diagnose clinically
Cataracts can be removed
Treatment-removal
Of see deep white thing in back of eye-retinoblastoma
Retinoblastoma
RB gene
Pt no have red reflex , have all white retina
Diagnosis clinical
Treatment surgical
Tempted to use radiation but NO that’s second hit and cause tumor
Right at puberty worry about osteosarcoma
Retinopathy of prematurity
Lungs aren’t ready premature so give high levels of fio2 can lead to problems of the eye if look in back see growths on retina
Actively looking for them diagnosis is clinical
Laser and ablate them
Anytime see 1 of 4 consider bronchopulmonary dysplasia
And interventricular hemorrhage assess with US Doppler, and NEC which present bloody bowel movement give NPO
Neonatal conjunctivitis
Chemical-silver nitrate used to prevent so burn baby eye onset within 24 hours on both eyes bilateral and non purulent, treatment not do anymore use topical erythromycin instead or tetracycline
Gonorrhea-can destroy eye. Day 2-7 bl and purulent aggressive, use erythromycin prophylaxis, presume and treat with ceftriaxone if see it, grow on chocolate agar and get PCR treat baby as have gonorrhae until prove otherwise
Chlamydia-indicative of systemic illness , no prophylaxis , 5-14 days starts as unilateral and mucous then turn purulent and then bl, treat with erythromycin orally, look for systemic illness and pneumonia please
Herpes-acyclovir can reduce duration
Bacteria-get culture chocolate agar and PCR for gonrrha, and most other bacterial are at day 5-14 treat presumptively for G and C until cultures come back
Left to right shunt
Hole
Increase pulm art flow and increase pulmonary arterial pressures. Increase the pulmonary arterial resistance. Right heart sees pulmonary HTN and get right heart hypertrophy and RV get big and beefy and right hear stronger than left and get eisenmingers syndrome reversal R-L and becomes cyanotic
Non cyanotic so not blue in morn
Atrial septal defect
Hole left atrium to right atrium
La->Ra
Diagnosed at any age
Most common congenital defect after age 1
Fixed split s2 is thing that tells you its ASD.
Echocardiogram diagnosis
Closure device for treatment
VSD
Hole LV->RV
<1 yo asymptomatic mumur
FTT, CHF
Diagnose with echo
Asymtpomatic wait year
CHF surgical repair
PDA
Aorta ->pulmonary artery connection persists
Oxygenated blood from aorta goes to patent ductus into pulmonary artery where mixes with deoxygenatino
Murmur not present on day zero
Continuous machine like murmur
Multiphasic continuous murmur
(Multiphasic friction rub-pericarditis)
Diagnose with echo
Treat closure when need it with INDOMETHACIN to end it
Right to left shunt
Catastrophic failure
Decrease pulm flow Cyanotic blue babies Day 0 Die T
Transposition of great vessels
Mom has diabetes and not gestational DM bc heart develops week 8
Failure to twist
RA-RV-aorta-VC never see oxygen
LA-Lv-pulm A-pulm V always oxygenated
Blue baby dies
Echo
Prostaglandins until surgery keep patent ductus open
INDOMETHACIN ends it
TOF
Endocardium cushion defect
Associated with Down syndrome
- VSD
- Overriding aorta
- Pulmonic stenosis
- RV hypertrophy
Deoxygenated blood
Present-blue baby dies, kid slightly older with TET spells squat improve venous return more blood to right ventricle
Echo
Surgery
Coarctation
Distal to great vessels
In descending
HTN UE-warm
Hypo LE-cool
Claudication-refuse walk
Diagnosis echo
Angiogram not in kids
X ray rib notching not for kid
Treat surgery
Hematuria
UA to tell micro or macro
Microscopic-self limiting , but exception is if had blunt trauma then do CT scan
Frank macro hematuria-need more investigation look at urine micro one of three things…dysmorphic cells squeezed through net or mesh or RBC cast looking at glomerular disease
UA and if need kidney biopsy
Normal RBC and no casts then have non glomerular causes(kidney stone, cancer, trauma) start with US then decide between cystoscopy vs systemic imaging like CT or MRI
UD, VCUG, CT, cystoscopy, pyelogram
Never pyelogram
US-1st step shows hydro=obstruction or reflux
VCUG-tells if hydro is obstruction or reflux. Object dye and have pee normal if pee and all goes out. If enf up in urethra it shows reflux. Is hydro from reflux
CT scan-on top of kidney. Trauma =IV contrast or think there are stone use noncontrast
Cystoscopy-in lumen intraluminal lesions bladder hematoma and cancer . Access to ureter can also fix when in there
Biopsy-probably wrong
Pyelogram-probably wrong
PUV
Can’t get urine out of bladder Redundant tissue No urine dilated bladder Present with or without oligohydramnios Plus or minus prenatal US Increase Cr
US=hydro
VCUG-r/o reflux
Catheter-output
Treat catheter, surgery
Hypo epispadias
Epi: dorsal
Hypo:ventral
Diagnosis clinical
Treatment -never circumscribe
——-rebuild
UPJO
Narrow lumen
Normal
Obstruction increase flow
Pt: teenager->etoh0>colicky abdominal pain->
Diagnosis-uS-hydronephrosis
VCUG-r/O reflux
Treat surgery with or without stent
Ectopic ureter
Normal-bladder
Abnormal-ectopic
Male asymptomatic
Girls normal function and constant leak and never dry
Diagnosis US show no hydro
VCUG r/o reflux
Then radionucleotide scan to assess renal function
Treat reimplant
Vessiculoureteral reflux
Path-retrograde
Prenatal US plus hydro
Recurrent UTIS plus pyelonephritis
US=hydronephrosis VCUG=reflux
Treat abx and surgery
Kids immunodeficiency
Unusual pathogens
Failure to thrive with diarrhea
Recurrent infection
Severe infections
Greater than 6 months bc mom antibodies
Work up =CBC with diff, quantative Igg (A, G, M)
Treat avoid pathogens cant fight and give what dont have
B cell immmunodefiency XLA (Butons)
X linked
No Iga in blood
Effects boys
Defiency B cells
Present 6 months
Sinopulmonary infections,
Diagnosis CBC =normal, quantative immunoglobulin-no iga, g, or m absolutely absent
Flow cytomegalovirus no B cells
Confirm with RTK gene
Treat-IV iGG to fight infections can do bone marrow transplant
CVID
Mild form of XLArecurrent sinopulmonary but teen or older child must be less severe form
CBC normal, quantitative immunoglobulin show decrease in 2/3 immunoglobulins
Less severe
Treat can give IGG not bone marrow transplant
IgA defiency
Reduced iga cant fight mucosal defenses
Present things exposed to the outside
May see sinopulmonary infections, bouts of GI bugs , usually asymptomatic though until get blood transfusion then go anaphylactic
CBC normal quantative IG show decreased Iga but increased IGG and IGM which is why asymptomatic
Since usually asymptomatic dont treat but watch for anaphylaxis with transfusions
Hyper igm
Can’t convert igm to igg
Igm bind everything igg particular
Have nonspecific immune defiency
Start with CBC normal
Get quantitative immunoglobulins have decrease igg, iga and massive increase igm
Treat not warranted
DeGEorge syndrome
22q11,2 deletion
Problem of third pharyngeal pouch
Patient have wide spaced eyes
Low set eats
Absent thymic shadow on x ray
Small face
Fungi and PCP infections
Diagnosis clinical
Have syndrome all you need
CDC reduced ALC
Treat wit tMP SMX for PCP proph, IVIg as bridge to thymic transplant
Watch out for hypocalcemia from no PTH tetany seizures ,
T cells
Wiskott aldrich
X linked Boys Ezcema Low platelets Normal infection
CBC decrease WBC and low platelet Ed
Quantative igg increase igm and igg
Treat with bone marrow transplant
Ataxic Natalya is
Ataxia
Telangectasia
Immunodefiency
DNA repair , leukemia, lymphoma
SCID
No immune system no defense
Kids mega aids
No B no T
Adenosine deaminase defiency
Immunodefiency immediately and any exposure infection
Mega aids but HIV negative and no exposure
Diagnose CBC decrease WBC
Quantative no igm, igg or iga
Treat isolate bubble baby must be sealed in plastic otherwise they die TMP. SMX against PCP proph
Bone marrow transplant die
Chronic granulomatousdisease
No response burst macrophages can eat bacteria but cant kill catalase positive organisms
Present with staph abscesses recurrent
Diagnosis nitroblue CBC increase WBC quantative see increase IGM and IGG
Treat bone marrow transplant
Leukocytes adhesion defiency
WBC cant leave the blood
High fever, high leukocyte count, NO PUS
Delayed separation of cord neutrophils dont cleave it off
Treat with BMT
Chediak higashi
AR
Giant granules in neutrophils
Can be associated with albinism neuropathy and neutropenia
C1 esterase defiency
Spontaneous non drug related ANGIOEDEMA
Give FFP
Neisseria
C5-C9 mac attack
Charge sydnrome
Choanal atresia Heart defects Atresia of the choanae Retardatoin of growth and/or development Genital and/or urinary defects Ear anomalies and/or deafness
Turn blue when feeding and pink with crying
Baby/kid hypotensive/unstable and cant get peripheral IV line
Do intraosseous catheter bedside usually tibia done in emergency situations when cant get peripheral IV
Central venous catheters take longer
Arterial lines for continuous blood pressure monitoring
NG fluids through tube good for moderate dehydration, not if in shock
Any concern for abuse
Always ask about abuse before doing therapy. Must figure out when child alone. It is a priority
