Pulm and GI Flashcards
Typical vs atypical pneumonia
typical = acute onset, lobar consolidation on x-ray, involves pneumococcal spp
atypical = more indolent (> 24hrs) onset, lower peak temps, more prodromal sx like headache and sore throat, involves mycoplasma or chlamydia spp
More likely to see what kind of pneumonia in school age children
Atypical
More likely to see what kind of pneumonia in neonates
Group B Strep, Chlamydia
More likely to see what kind of pneumonia in infants outside neonate period
Viral pneumonia
Serious bacteria pneumonia w staph aureus, strep pneumo
Ill / toxic apearing child may be more likely to have what kind of pneumonia
Bacterial pneumo, or a complication of bacterial pneumo like empyema
When considering pneumonia, what else should beo n the DDX
Atelectasis from foreign body or mucus plug
A 2 year-old presents with the abrupt onset of cough, wheeze and tachypnea. He is afebrile. Physical exam reveals diminished air exchange and wheezing on the right.
What’s the DDx?
Foreign body aspiration
Asthma
Pneumonia
Bronchiolitis
Tx for complete airway obstruction
back slaps and chest thrusts in head down position for infants, abdominal thrusts for older children
Tx for partial airway obstruction
allow patient to cough, take to nearest emergency facility
Rigid bronchoscopy
Male infant born at 38 weeks by scheduled repeat cesarean section prior to onset of labor.
Maternal history – good prenatal care, negative group B Strep cultures
Apgars 8/8
Within first hour of birth:
Tachypnea
Nasal flaring
Mild retractions
What’s the DDx?
Transient tachypnea of the newborn
Respiratory distress syndrome
Congenital diaphragmatic hernia
Meconium aspiration syndrome
A 10 month-old presents with bouts of irritability during which he draws up his legs and appears to be in pain. He had a viral illness last week. His stools are heme test negative and he is very lethargic. There is abdominal distention and diffuse tenderness. What is your differential diagnosis?
Intussusception
Malrotation w/volvulus
Meningitis
Gastroenteritis
A full-term 1-week-old boy presents with bilious vomiting and lethargy
Pertinent history: normal prenatal course, uncomplicated delivery, adequate weight gain since birth
Physical exam: fussy, pale, abdomen distended and tender to palpation, blood in diaper
Most likely diagnosis?
Malrotation w volvulus
Gonna need surgery
An 8 year-old girl presents with abdominal pain, purpuric lesions on the buttocks and lower extremities, and knee and ankle pain. She reports her urine to be darker than usual.
Most likely diagnosis?
Henoch-Schonlein Purpura
Vasculitis:
- *palpable purpura on lower extremities
- hematuria, bloody stools
- *edema
RLQ pain, abdominal guarding and rebound tenderness
Appendicitis
Diarrhea – possibly bloody, fever, vomiting
Bacterial enterocolitis
RUQ pain, may extend subscapular
Cholecystitis
Purpuric lesions, joint pain, blood in urine, guaiac-positive stools
Henoch-Schonlein Purpura
RUQ pain, jaundice
Hepatitis
Inguinal mass, lower abdominal or groin pain, emesis
Incarcerated inguinal hernia
Colicky abdominal pain, currant jelly stools
Intussusception
Abdominal distention, bilious vomiting, blood per rectum, usually presents in infancy
Malrotation with volvulus
Hematuria, colicky abdominal pain
Nephrolithiasis
(Severe) epigastric, abdominal pain, fever, and persistent vomiting
Pancreatitis
Emesis, history of prior abdominal surgery
Small bowel obstruction
Fever, sore throat, headache, +/- abdominal pain
Streptococcal pharyngitis
Fever, vomiting, and diarrhea in infants; back pain in older children
UTI
Irritability, pallor, bloody diarrhea, anemia, thrombocytopenia
Hemolytic-uremic syndrome
Weight loss, diarrhea, malaise
Inflammatory bowel disease
CXR appearance of RDS
“Ground glass” - fine reticular granularity
Initial CXR may be normal, w progression over 6-12hrs
Most common lower respiratory tract infection in infants and children <2yo
Bronchiolitis
Most common causative agent of bronchiolitis
RSV
Adenovirus, parainfluenza, influenza
Bronchiolitis - diagnosis studies?
Clinical diagnosis - labs and imaging not recommended
Recent URI, copious rhinorrhea
Cough, tachypnea, tachycardia
Nasal flaring, grunting
Bronchiolitis / RSV
Earliest, most sensitive sign for bronchiolitis / RSV
Tachypnea
Bronchiolitis / RSV management
Hydration!!!
Oxygenation
Nasal suction
Ribavarin only for severe cases
Leading cause of infant death from viral infection
RSV
Most common complication of RSV
Otitis media
Recurrent Wheezing vs Chronic Asthma
Recurrent wheezing more in early childhood, triggered by viral URI’s
Chronic asthma is associated w allergy and persists into later childhood / adulthood
Intermittent dry coughing and expiratory wheezing
SOB and chest tightness in older children
Symptoms worse at night
Asthma
Expiratory wheezing, prolonged expiratory phase
Asthma
Acute inflammatory upper airway obstruction, ddx
Croup Epiglottitis Aspiration of foreign body Retropharyngeal or pertonsillar abscess Extrinsic compression of the airway (laryngeal web, vascular ring
URI sx for 1-3 days
Barky cough, hoarseness, inspiratory stridor
Croup
Age group most common for Croup
3 month - 5 years, peaks at 2 yrs
Most common etiology and long medical name for Croup
Parainfluenza virus
Laryngotracheobronchitis
CXR indicating Croup
“Steeple sign” - upper trachea appears closed, gradually opens as it descends
Croup management at home
Airway management, usually done at home
- cool mist
- steamy bathroom
Croup management in ED
Nebulized racemic epinephrine
Corticosteroids
When to hospitalize for croup?
Severe stridor at rest Respiratory distress Hypoxia Cyanosis Depressed mental status
Acute, fulminating course of high fever, sore throat, dyspnea, rapidly progressing respiratory obstruction
Acute Epiglottitis
Epidemiology of epiglottitis
In the past was largely due to Haemophilus influenzae type b
now usually due to Streptococcus pyogenes, Streptococcus pneumoniae, and Staphylococcus aureus
Otherwise healthy child suddenly develops a sore throat and fever
Within few hours – toxic appearing, difficulty swallowing and breathing
Drooling
Acute Epiglottitis
Diagnosis of epiglottitis
Visualization of a large, “cherry-red” swollen epiglottitis
Should only be performed by someone capable of maintaining airway – i.e. ENT or anesthesiologist
CXR of acute epiglottitis
“thumb sign”
Epiglottitis management
Airway establishment - intubation
O2
Blood Culture
Antibiotics - ceftriaxone, cefixime
Etiology and course of whooping cough / pertussis
6 week course
Bordatella pertussis
Evolves into inexorable paroxysms – hallmark of the disease
Number and intensity of paroxysms progresses over days to a week and then plateaus for days to weeks
Whooping cough / pertussis
reportable disease
Suspect in patient who has predominant complaint of cough especially in the absence of fever, malaise, myalgia, exanthema or sore throat
Whooping cough / pertussis
reportable disease
Pertussis tx
Erythromycin or azythromycin
Hospitalize infants under 3 months
Pertussis complications
Pneumonia Seizures Apnea Secondary infection Mortality 1% in < 2month olds
Non-bilious emesis that becomes progressively forceful
Dehydration, weight loss
Birth- 3 months
Pyloric stenosis
First line testing for pyloric stenosis
Ultrasound
Look for thickening of pyloric valve, elongation of channel
Metabolic panel in pyloric stenosis will show
hypochloremic metabolic alkalosis due to loss of hydrogen ions and chloride from emesis
Most common cause of intestinal obstruction in children aged 3 months to 6 years of age
Intussusception
60% occur before first birthday
80% occur before second birthday
Uncommon < 3 months, > 6 years
Intussusception usually occurs at what part of bowel
ileocecal junction
Pathophys of intussusception
Obstructs venous return ➔ engorgement of intussusceptum ➔ edema, bleeding from the mucosa ➔ bloody stool (CURRANT JELLY STOOL)
Intussusception Tx
Hydrostatic/ pneumatic reduction – with barium or water soluble contrast
Successful 80-95% of the time
Recurrence: 10%
Surgical reduction
Manual reduction of intussusceptum
Resection for ischemia
True diverticulum, containing all bowel layers (mucosa, submucosa and muscularis propria), in small intestine
Most common congenital GI abnormality
Meckel’s diverticulum
Most common times constipation presents
Infancy: at transition to solid foods
Toddler: at transition to toilet training
School-age: at entry to school
“Voluntary or involuntary passage of feces into inappropriate places at least once a month for 3 consecutive months once a chronologic or developmental age of 4 has been reached”
Encoparesis
4% in 5 – 6 year olds
1.5% in 11 – 12 year olds
M:F = 4-5:1
