Peds CLIPP Flashcards
3 types of dehydration
Isotonic/natremic ( Na = 130-150)
Hypotonic/natremic (Na<130)
Hypertonic/natremic (Na>150)
Most common type of dehydration in children, i.e. acute gastroentertitis and diarrhea
Isotonic…Na and H20 losses are balanced
Deficit in ____ dehydration can be replaced over ____ hours:
Isotonic - 12
Hypotonic - 24
Hypertonic - 48
In a patient that is Z% dehydrated, how do you calculate pre-illness weight?
Current weight/((100-%dehydrated)x.01)
When DKA pt is dehydrated, how much fluid needs to be given over next 24-48 hours (DKA pt, we specify 48 hours)
kg deficit x 1000mL/kg = #mL fluid deficit (and thus amount needed to be given)
Deficit = Pre-illness weight - current weight = # kg deficit;
For maintenance fluids in a dehydrated patient, are calculations based off current weight or pre-illness wt?
Pre-illness weight!
Signs of Cerebral Edema
- headache
- recurrent vomiting
- bradycardia
- hypertension
- hypoxia
- restlessness/irritability
- lethargy
- CN palsies
- Abnormal pupillary responses
Tx of cerebral edema
- Slow rate of fluid admin
- IV mannitol
- ICU
Components of admission orders
A dmit
D x
C ondition
V itals A ctivity N ursing D iet I V fluids S tudies M eds A llergies L abs
Why do you need to do hourly neuro checks on DKA pt?
Cerebral edema = most serious
complication of DKA
Children with new-onset T1DM should also be screened for:
Autoimmune thyroid disease (thyroid Ab) and Celiac (endomysial/tissue transglutaminase)
Screening recommendations for T2DM in children
Fasting plasma glucose @ 10yo or @onset of puberty, then q3 years after that (for children overweight + 2 risk factors)
When would you expect fever as an adverse rxn from vaccines?
within 24-48 hours
Temp>101F for at least 2 weeks with failure to reach dx after 1 week evaluation
Fever of Unknown Origin
Fever without an identified etiology after a complete H and P performed
Fever without source
usually viral
Almost all children with elevated wbc represent:
FALSE POSITIVES…bacteremia rates are really low now due to vaccines
WBC<15,000 is ____ at ruling out bacteremia
Excellent
T/F: Majority of immunized, immunocompetent 3-36 mo chidren with fever should get empiric therapy with ceftriaxone or other antibiotics
False…most will not have bacteremia so this is not appropriate
Kernig and Brudzinski signs test for:
meningitis (if +, do LP)
Flexion of one of the legs 90 deg @ hip and knee in resposne to flexion of neck =
Brudzinski’s sign (meningitis)
Resistance to extension of the knee =
Kernig’s sign
meningitis
define occult bacteremia
+blood culture in a well-appearing child (most will not develop a serious bacterial illness)
Is a red TM + fever enough for AOM dx?
Nope. Need poor mobility and at least mild bulging of TM
Commonly caused by enterovirus; presents with fever; may have loose stools, rashes, or URI sxs
Viral meningitis
What’s more worrisome, bacterial or viral meningitis?
Bacterial
T/F: Basically always put UTI on the ddx in a young infant/child with fever without source, even if common UTI sxs not present
TRUE….get UA AND Urine culture (when antimicrobial therapy initiated, need a catheterized specimen, not bagged urine)
T/F: Nitrofurantoin is first line for cystitis and pyelo
False, only for cystitis. Only concentrates well in urine, not in blood.
Best choice antibiotic for pyelo
Keflex (cephalexin)
Follow up studies after 1st episode Pyelo:
Ultrasound of Kidneys and Bladder (better than the IVP)
FU studies after 2nd ep of febrile pyelo
do a Voiding Cystourethrogram (VCUG) –> demonstrates presence of Vesicourethral Reflux
Infant is expected to regain his birth weight by ______ age
2 weeks of age
Failure to regain birth weight by ____ weeks of age, or continous weight loss after _____ days = FTT
3 weeks; 10 days
Failure to Thrive
An infant is considered adequately nourished in the first few weeks if they receive ____ feedings per day (you expect at least ____ wet diapers/day)
6; 6
should encourage 8-12 feedings though
How much vit D supp do breast fed infants need?
400 IU daily beg. w/in first few days
Infant feeds should be approximately every:
2-3 hours. (4 hours is probably too long of intervals) for 10-15 min
- poor/absent eye movements
- or, failure of child to recognize parents or objects in environ.
Lethargy def.
Normal size of anterior fontanelle…do ((length +width)/2)
- 1cm
- 6-3.6 = 2 SDs (95%)
Posterior usually
Conditions causing large fontanels
- skeletal disorders (rickets, Osteo Imperfecta)
- Chromosomal (Downs)
- Hypothyroid
- Malnutrition
- Increase ICP
Conditions causing small fontanels
- Microcephaly
- Hyperthyroidism
- Craniosynostosis
- Normal variant
Conditions causing sunken fontanels
Dehydration
Conditions causing bulging fontanels
- Meningitis
- Hydrocephalus
- Subdural hematoma
- Lead poisoning
Hypotonia, large fontanels, umbilical hernia, and jaundice
Congenital Hypothyroidism
Poor feeding, vomiting, lethargy that occurs after about 2 days of life
Inborn error of metabolism. Symptomatic aftr few days due to protein load in breast milk/formula
Na and K levels in CAH?
Low sodium, high potassium
Where does majority of bilirubin in newborn come from?
Physiologic breakdown of red blood cells
Where and how is bilirubin conjugated?
Liver; bilirubin conjugated to glucuronide by UDP Glucuronyl transferase (UDPGT)
How is bilirubin excreted?
Conjugation in the hepatocytes makes it awter soluble; excreted into the bile and then intestines (stool)
Why do newborns absorb so much more of bilirubin from stool (meconium)?
Lack GI flora to metabolize bile; b-glucuronidase in meconium converts CB –> UCB –>reabsorbed into blood stream –>binds albumin
What are some sequelae of kernicterus (staining of BG and CN by bilirubin)?
- Lose suck reflex
- lethargy
- hyperirritability
- seizures
- death
if survive:
- opisthotonus
- rigidity
- oculomotor paralysis
- tremors
- hearing loss
- ataxia
Why have rates of kernicterus in newborns decreased?
Screening for Rh incompatibility and use of Rhogham
(erythroblastosis fetalis)…its a hemolytic rxn. Also, tx of UCBemia with phototherapy
Who is at higher risk of jaundice, breastfed or formula-fed infants?
Breast
Physiologic jaundice = total bilirubin < ____ mg/dL
15
seen in almost all newborn infants
What factors promote physiologic jaundice
Increased enterohepatic circulation:
- increased bili production (breakdown of fetal rbc)
- Def of hepatocyte proteins/UDPGT
- Lack of intestinal flora to metab bile
- High b-glucuronidase in meconium
- low PO first few days life = slow excretion of mec (esp. breastfed)
Breast_____ jaundice occurs early in 1st week, when milk supply is low
breastFEEDING
Why does breastfeeding jaundice occur?
Low milk = dec. GI motility = retention of meconium, which has beta glucornidase = deconjugation of bili = reabsorbed via enterohepatic circ = elevated serum
T/F: Breast-milk jaundice is because of low breast milk volume
FALSE, this describes breastfeeding jaundice
What is ABO incompatibility?
Mother is Type O, baby is type A or B
T/F: Infants gain 1oz/day after birth for the first 2 months
False; they lose up to 10% during first 5 days, regain it by 2 weeks
T/F: Maternal infections can cause IUGR and newborn SGA with hyperbilirubinemia
True
Breast milk jaundice begins 4-7 days and may be caused by _______ present in breast milk which does what?
B-glucuronidase –> deconjugaes bilirubin the GI tract, and the UCB reabsorbed via enterohepatic circulation
T/F: Breastfeeding jaundice is because the feeding isn’t sufficient enough, whereas breastmilk is due to something in the milk
True…with feeding, not enough milk being made. With milk, b-glucuronidase in the milk deconjugates.
When should stool start becoming yellow (no more meconium)?
day 3
Healthy-appearing infant who develops jaundice, dark urine, and acholic (pale) stools btwn 3-6 weeks of age
Possibly biliary atresia
How do you evaluate jaundice in infant that’s >2 weeks old?
Fractionated bilirubin (total and direct)
Kasai procedure when is it indicated?
Used to restore bile flow/prevent liver damage in pt with biliary atresia (if done early)
Kasai procedure
what is it?
Anastomosis of the intrahepatic bile ducts to a loop of intestine to allow bile to drain directly into the intestine
Who has higher incidence of jaundice, breastfed or formula-fed?
Breastfed…however, usually not an indication to stop breast feeding
List some major risks for adverse outcomes of neonatal hyperbilirubinemia
- Jaundice in first 24 hrs
- Coombs
- gest. age 35-36wk
- Previous sibling had phototherapy
- Cephalohematoma
- East Asian
causes of congenital hypothyroidism
- Thyroid dysgenesis (aplasia, hypoplasia, ectopic gland) = #1 US
- iodine def #1 world
- Mother with Graves tx with antithyroid (transient in infant)
Signs of infant hypothyroidism
- feeding problems
- low activity
- constipation
- prolonged jaundice
- skin mottling
- umbilical hernia
Why is early detection fo sickle cell disease important in newborn screening?
Early penicillin prophylaxis can prevent sepsis secondary to Strep pneumo infection
What is the follow-up protocol after treating congenital hypothyroidism?
TSH and T4 measured at 2 and 4 weeks post initiating therapy, then:
- q1-2mo until age 1
- q2-3mo until age 3
- q3-12mo until growth completed
Approximate bili level when jaundice on face vs jaundice past the knees
5 mg/dL
10 mg/dL
Which of the following physical findings could contribute to hyperbilirubinemia: Cephalohematoma, Caput Succedaneum, Bruisng
Cephalohematoma (localized to cranial bone traumatized during delivery)
Bruising –> bleeding can = increased bili production b/c blood extravasated into tissues is broken down and converted to bili
(Caput swelling consists of serum so does not)
What is Developmental Dysplasia of the Hip
aka congenital dislocation of hip…partial or complete dislocation and instability of femoral head
Risk factors for developmental dysplasia of the hip
Breech position; Female gender; FHx
When do you order urine for reducing substances?
When suspecting Galactosemia (galactose = reducing substance)
Father is Greek and possibly has G6PD def. When do you test the daughter?
You don’t need to…its an X-linked recessive, so you would only test son or if mom is also greek
When would you test urine for bilirubin?
When suspecting Cholestasis (so NOT whenever there is jaundice…for this, total serum bilirubin)
Total serum bilirubin vs Direct bili/urine dipstick bili
Total serum bili: If jaundice in 1st 24 hours or w/significant jaundice
Direct/urine: Infant has dark urine/light stools ( atresia), infant is ill (sepsis)
When is the optimal time for neonatal screen?
Testing >24hrs after birth. If obtained before, need second specimen
T/F: Bronchodilators and steroids are generally not helpful in tx of wheezing in infants with viral respiratory illness
True
How does responsiveness to bronchodilators/steroids in a wheezing child help with dx?
Points to asthma
When do we use the phrase “Reactive Airway Disease”?
Controversial…appropriate for younger children with chronic wheezing without a dx of asthma yet (i.e. many kids will not continue to wheeze beyond 2-3 years)
How can you assess depth/degree of effort for Tachypnea?
- Hyperpnea (increased depth of resp): suggests non-pulm condition (fever/acidosis/anxiety) if no resp distress
- Hypopnea (reduced tidal V): may have hypoventilation in the setting of normal/elevated RR
What do nasal flaring and head bobbing indicate?
Both indicated significant resp distress and that accessory muscles are being used for respiration
What does grunting indicate?
Resp distress…forced expiration against partially closed GLOTTIS…help generate POSITIVE PRESSURE to stent airways open
Which is most severe indicator: Tachypnea, Grunting, Head Bobbing, Nasal Flaring, or Paradoxical Breathing?
Paradoxical breathing
What is paradoxical breathing?
- Sign of sig. resp. distress
- Force of contraction generated by diaphragm>ability of chest wall mm. to expand rib cage
- chest drawn in w/inspiration, abdomen rises
Respiratory muscle fatigue can reduce signs of respiratory distress, even though pt’s condition is worsening. How can you assess status?
Get blood gas –> may show elevated PCO2 = hypoventilation
Wet cough vs dry cough
Dry is typical of chronic asthma
Wet suggests secretions in the airway, due to a viral infection, post-nasal drip (allergies/sinusitis), GERD, CF, etc
coughing with liquids is suggestive of _____, dysphagia with solids suggestive of ______
liquids: Aspiration (i.e. TEF)
solids: Narrowing
How does assessing if voice or cry has been hoarse help with ddx of cough/wheezing?
Hoarseness/muffled sound = larynx/pharynx = pharyngitis, tonsillitis, epiglottitis (upper airway)
Problems with lower airway don’t affect quality of voice or cry
In a coughing child without vaccinations, what are you most concerned about?
Pertussis
what are the 3 phases of pertussis?
- Catarrhal (1-2 wks, URI)
- Paroxysmal (4-6 wks, whooping/forceful cough)
- Convalescent…decrease freq/severity of cough, can have episodic cough for months
Child is immunized and has epiglottitis (tripod position). What is likely etiology?
Staph or Strep
3 things that cause cough with wheeze
- Asthma,
- Bronchiolitis
- Foreign body aspiration
4 things that cause cough with rhinorrhea
- Allergic rhinitis
- pertussis (catarrhal stage)
- Sinusitis
- Viral URI
Finer breath sounds heard on inspiration associated with either fluid in the alveoli or with opening and closing of stiff alveoli (as in interstitial disease).
Crackles
rationale for inspiratory/expiratory films
irway containing an obstruction does not allow the distal lung to deflate fully and results in asymmetric deflation with expiration.
Soft-tissue neck films
croup or another supra- or subglottic abnormality
Soft-tissue neck films
croup or another supra- or subglottic abnormality
Chest x-ray findings in asthma
hyperinflation due to air trapping, increased interstitial markings and patchy atelectasis.
Maintenance therapy for chronic asthma
inhaled corticosteroid as a daily, controller medication, with an inhaled beta-agonist such as albuterol as needed for breakthrough symptoms.
most common cause of wheezing in infants
Acute bronchiolitis is a viral disease rsv
Chest radiographs Acute bronchiolitis
hyperinflation, increased interstitial markings, peribronchial cuffing, and scattered atelectasis from bronchial obstruction.
Chest radiographs Acute bronchiolitis
hyperinflation, increased interstitial markings, peribronchial cuffing, and scattered atelectasis from bronchial obstruction.
most common cause of pneumonia in children
Adenovirus
RSV
Parainfluenza
Influenza
When do you label cough as chronic?
> 4 weeks
coughing thats worse at night
- asthma
- sinusitis
(note: GERD not in this list for kids)
cough ass. with gagging or choking
GERD
paroxysmal cough
Pertussis
Chlamydia
Mycoplasma
Foreign body
paroxysmal cough
Pertussis
Chlamydia
Mycoplasma
Foreign body
hallmark of primary tb
primary complex (relatively large size of the hilar lymphadenopathy compared with the relatively small size of the initial lung focus
+PPD aka mantoux test for TB
> 5 mm in high-risk children
10 mm in moderate-risk children
15 mm in low-risk children.
Nasal congestion is a prominent feature, leading to complaint of nocturnal cough due to post-nasal drip
sinusitis
t/f: Bronchitis in children is thought to be due to extension of viral inflammation into the lower respiratory tree and does not require antibiotic therapy.
true
This is a term often used to describe when the lower eyelids appear darkened due to venous stasis.
Allergic shiners
This is the name for the infraorbital creases that appear due to intermittent edema caused by allergies.
Dennie-Morgan lines
This is the name for the infraorbital creases that appear due to intermittent edema caused by allergies.
Dennie-Morgan lines
How can we distinguish btwn viral and bacterial URI?
Bacterial persists without improvment; viral tends to improve gradually over a week
changes to I:E ratio in obstructive disease
Decreased I:E ratio (Expiration prolonged)
Hyperresonance on percussion of lungs
Localized air trapping behind a: -mucus plug
- foreign body
- mass
Dullness to percussion lungs
Lobar consolidation (aka airless) from pneumonia or atelectasis
Continuous, musical or polyphonic sounds generally heard during expiration
Wheezing
general causes of wheezing
Airflow through narrowed airways:
- Intraluminal (edema, mucus, FO)
- External compression (mass, lymphadenopathy)
Continuous, low-pitched, polyphonic sounds that occur during either inspiration a/o expiration
Rhonchi
What causes rhonchi?
(continuous low pitched sounds)
Mucus/secretion in the airways
Discontinuous lung sounds, either fine or coarse
Crackles
Are crackles inspiratory, expiratory, or both?
Typically Inspiratory
What causes crackles
Alveolar/small airway conditions =
- pneumonia
- pulm edema
- bronchitis
- interstitial disease
High-pitched inspiratory noise due to partial obstruction of larynx/trachea (extrathoracic airways)
Stridor
Which lung sounds are continuous?
Wheezes, Rhonchi
Which lung sounds are discontinuous?
Crackles
Bilateral nasal secretions lasting for more than 10 days in children
Sinusitis
may have sore throat/bad breath
Which lung sound is prominent in Bronchitis?
Rhonchi
also prominent in viral pneumonia
T/F: Wheezing is prominent in bronchitis
FALSE –>Rhonchi, no wheezing
The genetic predisposition to development of an IgE-mediated response to common aero-allergens
Atopy
most effective pharmacologic agents for tx of allergic rhinitis
Topical nasal steroids
should not be used for short-term sxs of seasonal allergies
History is key in asthma dx. What other test is the most specific for determination of asthma?
Spirometry (PFT) before and after bronchodilator therapy determines reversible obstructive airway disease (asthma)
When is bronchoprovacation (methacholine/histamine/exercise challenges) used?
Only when asthma is suspected and spirometry is normal
Chronic lung disease in which the airways are very sensitive, inflamed and narrowed = difficulty breathing. Tends to run in families. Variety of triggers can set off an episode (allegens, colds, exercise, stress)
Asthma
What is the first phase of the biphasic inflammatory response of asthma exacerbations?
1st phase: ~1 hour. mast cells and eosinophils release PG/LT = increased vascular permeability, mucus hypersecretion rapid bronchoconstriction
What is the second phase of the biphasic inflammatory response of asthma exacerbations?
Second phase: Starts 2 hrs after, peaks 4-8 hours, resolves 24 hours. Neutrophil, eosinophil, lymphocyte infiltration into bronchial epithelium = epithelial destruction, fibrotic remodeling, hyperplasia of bronchial smooth mm.
T/F: All pts with persistent asthma should get daily prophylaxis with anti-inflam therapy (inhaled corticosteroids)
TRUE
–>Beclomethasone (QVAR), Fluticasone, Budesonide (Pulmicort)
T/F: In well controlled asthma, Albuterol (SABA) aka “rescue” meds can be used daily
False. If well-controlled, should NOT be needed >2x/week…is jused more for exercise-induced asthma
Patients with asthma should make sure to have which vaccination?
Varicella…those on steroids are @ high risk for severe primary varicella infection
When doing spirometry, the standard time for exhalation is:
6 seconds
T/F: Breath-holding spells in children occur during inspiration and are reflexive in nature
False. They are reflexive but actually occur during expiration (child starts to cry an suddenly falls silent in the expiratory phase of respiration
breath holding spells: _____ associated with anger, ____ associated with injury/fall
Cyanotic (anger)
Pallid/acyanotic (falls)
Elevated BP in 2mo old indicates response from the CV system to:
- pain
- compensated shock
- increased ICP
Glasgow scale score > _____ = mild or no neuro compromise
13
Glasgow scale score
8
_____ hematomas result from head trauma, either accidental or non-accidental
Subdural
Prognosis for victims of abusive head trauma
Many with subdural hematomas and retinal hemorrhages have long term developmental delays, seizures, and difficulty with vision
common features Downs
- upslanting palp
- small ears
- flattened midface
- epicanthal folds
- redundant skin on back of neck
- hypotonia (most consistent finding)
T/F: FISH is the study of choice for dx of Down syndrome
False!
Its Lymphocyte Karyotype
Infants with down syndrome have an increased chance of having:
Hypothyroidism
