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Pediatrics > VLC Peds 3: Older children and Teens (5-17) > Flashcards

VLC Peds 3: Older children and Teens (5-17) Flashcards

1
Q

What findings would indicate need for urgent stabilization in a child?

A 
Altered mental status
Mottled skin
Cyanosis
Respiratory distress
Respiratory depression
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2
Q

What features, if found in a child you’re examining, should you notify your preceptor of reasonably quickly?

A

Fever
Pallor
Pain

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3
Q

What is Henoch-Schonlein purpura (HSP)?

A

self-limited, IgA-mediated, small vessel vasculitis

Typically involves the skin, GI tract, joints, and kidneys

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4
Q

What is the clinical presentation of HSP?

A

Child with bruising and leg pain (arthritis)

Child is otherwise well (no systemic Sx)

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5
Q

How often does a URI precede HSP?

A

Approx 50% of the time

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6
Q

What is the typical presentation of a coagulation disorder?

A

Easy bruising in deep tissues
Hemarthosis (painful bleeding into joints)

Can present with petechiae or superficial bruises

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7
Q

What is usually found in a detailed PMHx and FHx, in children with coagulation disorders?

A

Personal or family Hx of bleeding

eg after trauma, immunizations, circumcision, dental work

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8
Q

What is the presentation of idiopathic thrombocytopenic purpura?

A

Petechiae
Otherwise asymptomatic

Half of the time, preceded by non-specific URI

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9
Q

What is the clinical presentation of leukemia?

A

Constitutional Sx: fever, malaise, weight loss
Bone pain
Petechiae

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10
Q

How does leukemia cause petechiae?

A

Thrombocytopenia

due to bone marrow being replaced by malignant cells

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11
Q

What is the clinical presentation when a viral infection is causing skin changes?

A

Petechial rash
Low-grade fever
May have other constitutional complaints

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12
Q

How might petechiae be mechanically caused in an infected child?

A

Might be due to coughing and/or vomiting

If so, usually above the nipple line

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13
Q

Name one category of virus that can present with petechial rash

A

Enteroviruses

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14
Q

What is the clinical presentation of bacterial endocarditis?

A

Fever, fatigue, weight loss
Petechial rash is common
Bruising is uncommon

Fever may be low-grade

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15
Q

What symptoms might meningococcal septicemia present with?

A

Early stages are mild

Fever is usually present

Hemorrhagic rash (petechiae, purpura) can present at an advanced stage. Child is usually very ill.

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16
Q

What are the presenting symptoms of Rocky Mountain Spotted Fever?

A

High fever
Severe headache
Rash

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17
Q

What is the typical pattern of the rash in Rocky Mountain Spotted Fever?

A

Petechial

Starts on extremities, progresses centrally

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18
Q

Name 5 conditions on an initial DDx of bruising and leg pain in a child (8 on list)

A 
Coagulation disorder
Henoch-Schönlein purpura (HSP)
Idiopathic thrombocytopenic purpura (ITP)
Leukemia
Viral infection
Bacterial endocarditis
Meningococcal septicemia
Rocky mountain spotted fever
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19
Q

What conditions cause diffuse adenopathy?

A

Generalized infection
Malignancy
Storage diseases
Chronic inflammatory disease

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20
Q

Over what size are lymph nodes concerning?

A

> 2cm

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21
Q

Which lymph nodes are unlikely to be reactive (and thus raise concern when they are)?

A

Supraclavicular lymph nodes

Raise concern for lymphoma

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22
Q

Where can you usually palpate small lymph nodes in healthy children?

A

Cervical, axillary, and inguinal regions

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23
Q

What features of a lymph node suggest local infection or infection of the node?

A 
Tenderness
warmth
erythema 
fluctuance
edema
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24
Q

What features of a lymph node raise concern for malignancy?

A

Nodes that are hard, rubbery, matted together, or affixed to skin or soft tissue

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25
Q

What is the most common cause of splenomegaly in children?

A

Infection (e.g. Epstein-Barr virus, cytomegalovirus, bacterial sepsis, endocarditis)

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26
Q

What is synovitis?

A

joint swelling or

joint pain with limited ROM

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27
Q

What is the difference between arthritis and arthralgia?

A

Arthritis: true synovitis
Arthralgia: pain in or around joint without signs of synovitis

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28
Q

Aside from the most common cause, name 3 causes of splenomegaly in children (5 listed)

A

Most common is infection. After that:
hemolysis (sickle cell disease)

malignancy (leukemia, lymphoma)

storage diseases (e.g. Gaucher disease)

systemic inflammatory diseases (e.g. systemic lupus erythematosus, juvenile idiopathic arthritis)

congestion (a complication of portal hypertension)

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29
Q

What is the typical distribution of the rash in HSP?

A

Tends to primarily involve lower extremities

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30
Q

What is the etiology of joint pain in HSP?

A

Arthritis or arthralgia due to periarticular vasculitis

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31
Q

What labs should be ordered in suspected HSP?

A

CBC (r/o thrombocytopenic cause)
Urinalysis (assess for renal involvement)
BUN & Cr (assess renal involvement)

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32
Q

If you do labs for HSP, and the CBC comes back with thrombocytopenia, what should you be concerned about?

A

ITP or leukemia

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33
Q

What proportion of children with HSP have joint involvement?

A

3/4

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34
Q

What proportion of children with HSP have renal involvement?

A

1/3

1/4 of kids under 2yo

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35
Q

What proportion of children with HSP have abdominal involvement?

A

65% have colicky abdominal pain

50% develop intestinal bleeding, with guiac+ stool

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36
Q

What progression happens to 1/20 children with HSP?

A

About 5% of children with HSP progress to chronic renal failure.
<1% will develop end-stage renal disease.

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37
Q

What is the etiology of ITP?

A

antiplatelet antibody binds to platelet surface, leading to removal and destruction of platelets in the spleen and liver

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38
Q

What is the most common form of bowel obstruction in children 6mo-6y old?

A

Intussiception

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39
Q

True or false: intussiception usually clearly declares itself on presentation

A

False: Diagnosis requires a high index of suspicion, as the classic findings rarely present initially

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40
Q

What is the “classic” clinical presentation of intussiception?

A

Paroxysms of severe abdominal pain with inconsolable crying

Passage of “currant jelly” stool containing blood and mucus

Palpation of a “sausage-shaped” mass in the right abdomen

Additional SSx include vomiting, lethargy, and toxic appearance.

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41
Q

What is the recurrence rate of HSP?

A

30%

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42
Q

What needs to be determined to assess if someone is sick or not-sick (eg over the phone)?

A
  1. If they are still perfusing major organ systems
  2. How quickly the illness is progressing
  3. If the individual has any underlying conditions that raise the risk of serious illness (eg sickle cell, DM)
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43
Q

What would you ask about over the phone to confirm if a potential patient is perfusing major organ systems?

A

Brain (alert vs. lethargic)

Skin (well-perfused, flushed, or cool and clammy?)

Kidneys (urine output)

Lungs (respiratory rate? work of breathing? cyanosis?)

44
Q

What are the three main categories of condition that can cause acute mental status changes?

A

Hypoxia
Hypoglycemia
Shock (hypoperfusion)

45
Q

What is the most sensitive measure of adequacy of circulation?

A

Heart rate

Tachycardia is the first and most subtle sign of possible inadequate perfusion. (also the most commonly missed finding in pt who have been sent home, & return with serious illness)

46
Q

How do you assess a patient’s breathing?

A

Describe the effort and rate of breathing (RR, work of breathing)
Auscultate lungs
Check oxygenation.

47
Q

What symptoms do children have when in early shock?

A

Elevated HR
Elevated RR
Peripheral BV constriction (cool, clammy; increased cap refill time)
Decreased peripheral pulses

48
Q

What does hypotension imply in pediatric shock?

A

Children compensate well, so hypotension is a late sign: the child is in severe shock

49
Q

What are the types of shock?

A

Hypovolemic (incl hemorrhagic)
Cardiogenic (incl obstructive)
Distributive (neurogenic, anaphylactic, septic)

50
Q

What are the SSx of compensated or “warm” shock?

A 
Warm extremities
Bounding pulses
Tachycardia
Tachypnea
Adequate urination
Mild metabolic acidosis
51
Q

In what type of shock is compensated or “warm” shock seen?

A

Septic

52
Q

What are the most common causes of shock in children?

A

Hypovolemic (hemorrhage, diarrhea/dehydration)

Septic

53
Q

What should be administered first to children in shock?

A

Normal saline 20 mg/kg over 5 to 20 minutes

Maintaining perfusion overrides all other considerations in managing shock.

54
Q

In fluid resuscitation of children, boluses should be given up to what amount?

A

Give repeated boluses of isotonic fluids up to a total of 60 mL/kg

Start inotropic support (eg with dopamine) if perfusion remains inadequate

55
Q

In what order should routes of access be tried?

A

IV
then, for adults/teens: central line
then: IO

Last resort: venous cutdown

56
Q

What are the classic findings in bacterial meningitis in adults?

A

Nuchal rigidity
Fever
AMS
Kernig or Brudzinski sign

Each ranges from 44-100% of pt (depending on the study)

57
Q

How often are the classic findings of bacterial meningitis present in children?

A

Only about half of children

58
Q

What are the signs of meningitis in infants?

A

Dx/exam very difficult

Only bulging fontanelle and focal Sz associated in one study

59
Q

True or false: most cases of meningitis are related to outbreaks (eg in schools, military camps)

A

False: only about 5% are associated with outbreaks. Most are sporadic.

60
Q

What are the three syndromes that meningococcal disease presents with?

A

Meningitis

Meningitis with accompanying meningococcemia

Meningococcemia without clinical evidence of meningitis

61
Q

What are the early clinical signs of meningococcal disease?

A 
Fever
Chills
Malaise
Myalgia
Prostration
Rash (can be macular, maculopapular, petechial, or purpuric)
62
Q

What are the later clinical signs of meningococcal disease?

A 
Purpura
Limb ischemia
Coagulopathy
Pulmonary edema
Shock
63
Q

What is the overall case-fatality rate of meningococcal disease?

A

10% (higher in adolescents)

Coma and death can ensue within hours

64
Q

What are the sequelae of meningococcal disease, and what is the incidence of sequelae?

A

Hearing loss
Neurologic disability
Loss of digit/s or limb/s
Scarring

11% to 19% of survivors

65
Q

What is the DDx of fever and petechiae in a child?

A

Meningococcal sepsis
Toxic shock syndrome
Rocky mountain spotted fever
Bacterial endocarditis

66
Q

What is the clinical presentation of toxic shock syndrome?

A

high fever
hypotension
diffuse erythematous rash (looks like a sunburn, might feel rough to the touch) multiple organ dysfunction

67
Q

What must always be done when a patient presents with fever and petechiae?

A

Consider bacterial sepsis (even if pt looks otherwise well)

Blood culture done and Abx administered until it can be ruled out

Do not delay Abx for culture.

68
Q

What is the treatment for N. Meningitidis infection?

A

Abx, ASAP

  • Ceftriaxone
  • Vancomycin

Once definitive Dx,

  • penicillin G to eradicate organism
  • rifampin/ciprofloxacin/cextriaxone to eliminate carrier state
69
Q

When might you add doxycycline to the empiric treatment for a pt presenting with fever and rash?

A

In areas with endemic Rocky mountain spotted fever

70
Q

What steps should be taken for infection control prophylaxis when someone is considered to have meningococcal disease?

A

All household contacts and anyone having close contact during management of the patient should be treated: ciprofloxacin for adults and rifampin for children.

71
Q

What features do on note on initial evaluation of a child in office for cough?

A

Any signs of respiratory distress

  • Able to talk in full sentences
  • incr WOB
72
Q

What conditions are likelier if a cough is dry?

A

Environmental irritant

Asthma

73
Q

What conditions are likelier if a child’s cough is wet or productive?

A

lower respiratory infection

74
Q

What conditions are likelier if a child’s cough is barking?

A

Croup
Subglottic disease
Foreign body

75
Q

What conditions are likelier if a child’s cough is brassy or honking?

A

tracheitis

habit cough

76
Q

What is a “habit cough”?

A

A chronic, harsh, repetitive, barking cough that is absent once the child is asleep; occurs in the absence of underlying disease.

Psychological/psychogenic

May follow a viral illness.

77
Q

What conditions are likelier if a child’s cough is paroxysmal?

A

pertussis
chlamydia
mycoplasma
foreign body

78
Q

What conditions are likelier if a child’s cough is worse at night?

A

asthma
sinusitis
allergic or vasomotor rhinitis (postnasal drip)

79
Q

What conditions are likelier if a child’s cough disappears at night?

A

habit cough

80
Q

What conditions are likelier if a child’s cough is associated with gagging or choking?

A

GERD

81
Q

Why should you ask for more details when a child or parent reports “wheezing”?

A

Kids/parents can mean

  • wheezing
  • stridor
  • anything that causes noisy breathing (incl simple congestion)
82
Q

How might a child or parent describe shortness of breath?

A

Difficulty breathing
Difficulty keep ing up with playmates
Chest tightness

83
Q

What should be reviewed on ROS/assoc Sx for a child with cough?

A 
Change in voice
Chest pain
Choking event
Fever
Headaches
Sore throat
84
Q

What might a change in a child’s voice (with a cough) indicate?

A

Laryngeal irritation, due to chronic rhinitis or GER

85
Q

What might chest pain in a child with a cough indicate?

A

Gastroesophageal reflux

CHF due to myocarditis – rare, but often missed

86
Q

What might a headache indicate in a child with a cough?

A

Frontal or orbital headache might be caused by sinusitis

87
Q

True or false: most children with primary TB have severe symptoms.

A

False: most have few to none – 50% only found by contact tracing, despite radiologic evidence of diesease

88
Q

What is the most common abnormality on XR in children with primary TB?

A

Hilar adenopathy

89
Q

What are the presenting SSx of primary TB in infants and toddlers?

A

When they have SSx:
Nonproductive cough
mild dyspnea or wheezing (due to bronchial compression by enlarged lymph nodes)

Infants may present with failure to thrive

90
Q

What is the hallmark of TB (on lung imaging)?

A

Primary complex:

Large hilar lymphadenopathy, relative to initial focal lung parenchyma lesion

91
Q

What are allergic shiners?

A

Darkening of the lower eyelids as a result of venous stasis

92
Q

What is the “allergic salute”?

A

pushing the nose upward and backward with the hand to relieve nasal itching and obstruction

Over time, this may result in the development of a transverse nasal crease.

93
Q

What are Dennie-Morgan lines?

A

Infraorbital creases that appear due to intermittent edema caused by allergies.

94
Q

How quickly do ICS work?

A

ICS require several weeks of daily use before the beneficial effects are realized.

95
Q

How is a diagnosis of asthma made?

A

Clinically + spirometry

In a child <5yo, trial of albuterol instead of spirometry is acceptable (may not be able to cooperate with spirometry)

96
Q

What are the spirometry findings in obstructive lung disease?

A

Reduction in air flow and increased air trapping (d/t tight airways) reduces FEV1

FEV1/FVC ratio is lower

97
Q

What are the spirometry findings in restrictive lung disease?

A

Both FEV1 and FVC are lower

FEV1/FVC ratio is normal

98
Q

How are obstructive and restrictive lung diseases differentiated on spirometry?

A

FEV1/FVC ratio

Low in obstructive
Preserved (normal) in restrictive

99
Q

Why should a spacer be used with inhalers?

A

Without a spacer, almost all of the medication is delivered to the back of the throat

100
Q

What is PEF monitoring?

A

Peak Expiratory Flow monitoring

Compares PEF to child’s “personal best”, an average of PEF over 14d during a period of good control

101
Q

What is PEF monitoring used for?

A

Short-term monitoring

Managing exacerbations at home and in the emergency department

Daily long-term monitoring of asthma–particularly in moderate to severe asthma

102
Q

What are the diagnostic criteria of asthma?

A

Symptoms of recurrent airway obstruction by history and exam

Reversibility (at least partial)

Exclusion of other causes of obstruction

103
Q

What therapy should all pt with asthma have?

A

Daily prophylaxis with anti-inflammatory therapy (eg ICS)

104
Q

What side effects can occur with ICS?

A

Side effects are rare

Children on longterm ICS should be monitored for:

  • elevation in BP
  • blood sugar
  • growth delay
  • cataract development
105
Q

What treatment strategy can be employed in children with only seasonal symptoms of asthma?

A

daily use of anti-inflammatory medications (eg ICS), starting several weeks before the expected antigen exposure.

Pediatrics (8 decks)

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