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
2
Q
What features, if found in a child you’re examining, should you notify your preceptor of reasonably quickly?
A
Fever
Pallor
Pain
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
4
Q
What is the clinical presentation of HSP?
A
Child with bruising and leg pain (arthritis)
Child is otherwise well (no systemic Sx)
5
Q
How often does a URI precede HSP?
A
Approx 50% of the time
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
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
8
Q
What is the presentation of idiopathic thrombocytopenic purpura?
A
Petechiae
Otherwise asymptomatic
Half of the time, preceded by non-specific URI
9
Q
What is the clinical presentation of leukemia?
A
Constitutional Sx: fever, malaise, weight loss
Bone pain
Petechiae
10
Q
How does leukemia cause petechiae?
A
Thrombocytopenia
due to bone marrow being replaced by malignant cells
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
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
13
Q
Name one category of virus that can present with petechial rash
A
Enteroviruses
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
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.
16
Q
What are the presenting symptoms of Rocky Mountain Spotted Fever?
A
High fever
Severe headache
Rash
17
Q
What is the typical pattern of the rash in Rocky Mountain Spotted Fever?
A
Petechial
Starts on extremities, progresses centrally
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
19
Q
What conditions cause diffuse adenopathy?
A
Generalized infection
Malignancy
Storage diseases
Chronic inflammatory disease
20
Q
Over what size are lymph nodes concerning?
A
> 2cm
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
22
Q
Where can you usually palpate small lymph nodes in healthy children?
A
Cervical, axillary, and inguinal regions
23
Q
What features of a lymph node suggest local infection or infection of the node?
A
Tenderness warmth erythema fluctuance edema
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
25
What is the most common cause of splenomegaly in children?
Infection (e.g. Epstein-Barr virus, cytomegalovirus, bacterial sepsis, endocarditis)
26
What is synovitis?
joint swelling or
| joint pain with limited ROM
27
What is the difference between arthritis and arthralgia?
Arthritis: true synovitis
Arthralgia: pain in or around joint without signs of synovitis
28
Aside from the most common cause, name 3 causes of splenomegaly in children (5 listed)
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)
29
What is the typical distribution of the rash in HSP?
Tends to primarily involve lower extremities
30
What is the etiology of joint pain in HSP?
Arthritis or arthralgia due to periarticular vasculitis
31
What labs should be ordered in suspected HSP?
CBC (r/o thrombocytopenic cause)
Urinalysis (assess for renal involvement)
BUN & Cr (assess renal involvement)
32
If you do labs for HSP, and the CBC comes back with thrombocytopenia, what should you be concerned about?
ITP or leukemia
33
What proportion of children with HSP have joint involvement?
3/4
34
What proportion of children with HSP have renal involvement?
1/3
| 1/4 of kids under 2yo
35
What proportion of children with HSP have abdominal involvement?
65% have colicky abdominal pain
| 50% develop intestinal bleeding, with guiac+ stool
36
What progression happens to 1/20 children with HSP?
About 5% of children with HSP progress to chronic renal failure.
<1% will develop end-stage renal disease.
37
What is the etiology of ITP?
antiplatelet antibody binds to platelet surface, leading to removal and destruction of platelets in the spleen and liver
38
What is the most common form of bowel obstruction in children 6mo-6y old?
Intussiception
39
True or false: intussiception usually clearly declares itself on presentation
False: Diagnosis requires a high index of suspicion, as the classic findings rarely present initially
40
What is the "classic" clinical presentation of intussiception?
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.
41
What is the recurrence rate of HSP?
30%
42
What needs to be determined to assess if someone is sick or not-sick (eg over the phone)?
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)
43
What would you ask about over the phone to confirm if a potential patient is perfusing major organ systems?
Brain (alert vs. lethargic)
Skin (well-perfused, flushed, or cool and clammy?)
Kidneys (urine output)
Lungs (respiratory rate? work of breathing? cyanosis?)
44
What are the three main categories of condition that can cause acute mental status changes?
Hypoxia
Hypoglycemia
Shock (hypoperfusion)
45
What is the most sensitive measure of adequacy of circulation?
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
How do you assess a patient's breathing?
Describe the effort and rate of breathing (RR, work of breathing)
Auscultate lungs
Check oxygenation.
47
What symptoms do children have when in early shock?
Elevated HR
Elevated RR
Peripheral BV constriction (cool, clammy; increased cap refill time)
Decreased peripheral pulses
48
What does hypotension imply in pediatric shock?
Children compensate well, so hypotension is a late sign: the child is in severe shock
49
What are the types of shock?
Hypovolemic (incl hemorrhagic)
Cardiogenic (incl obstructive)
Distributive (neurogenic, anaphylactic, septic)
50
What are the SSx of compensated or "warm" shock?
```
Warm extremities
Bounding pulses
Tachycardia
Tachypnea
Adequate urination
Mild metabolic acidosis
```
51
In what type of shock is compensated or "warm" shock seen?
Septic
52
What are the most common causes of shock in children?
Hypovolemic (hemorrhage, diarrhea/dehydration)
| Septic
53
What should be administered first to children in shock?
Normal saline 20 mg/kg over 5 to 20 minutes
Maintaining perfusion overrides all other considerations in managing shock.
54
In fluid resuscitation of children, boluses should be given up to what amount?
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
In what order should routes of access be tried?
IV
then, for adults/teens: central line
then: IO
Last resort: venous cutdown
56
What are the classic findings in bacterial meningitis in adults?
Nuchal rigidity
Fever
AMS
Kernig or Brudzinski sign
Each ranges from 44-100% of pt (depending on the study)
57
How often are the classic findings of bacterial meningitis present in children?
Only about half of children
58
What are the signs of meningitis in infants?
Dx/exam very difficult
Only bulging fontanelle and focal Sz associated in one study
59
True or false: most cases of meningitis are related to outbreaks (eg in schools, military camps)
False: only about 5% are associated with outbreaks. Most are sporadic.
60
What are the three syndromes that meningococcal disease presents with?
Meningitis
Meningitis with accompanying meningococcemia
Meningococcemia without clinical evidence of meningitis
61
What are the early clinical signs of meningococcal disease?
```
Fever
Chills
Malaise
Myalgia
Prostration
Rash (can be macular, maculopapular, petechial, or purpuric)
```
62
What are the later clinical signs of meningococcal disease?
```
Purpura
Limb ischemia
Coagulopathy
Pulmonary edema
Shock
```
63
What is the overall case-fatality rate of meningococcal disease?
10% (higher in adolescents)
Coma and death can ensue within hours
64
What are the sequelae of meningococcal disease, and what is the incidence of sequelae?
Hearing loss
Neurologic disability
Loss of digit/s or limb/s
Scarring
11% to 19% of survivors
65
What is the DDx of fever and petechiae in a child?
Meningococcal sepsis
Toxic shock syndrome
Rocky mountain spotted fever
Bacterial endocarditis
66
What is the clinical presentation of toxic shock syndrome?
high fever
hypotension
diffuse erythematous rash (looks like a sunburn, might feel rough to the touch) multiple organ dysfunction
67
What must always be done when a patient presents with fever and petechiae?
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
What is the treatment for N. Meningitidis infection?
Abx, ASAP
- Ceftriaxone
- Vancomycin
Once definitive Dx,
- penicillin G to eradicate organism
- rifampin/ciprofloxacin/cextriaxone to eliminate carrier state
69
When might you add doxycycline to the empiric treatment for a pt presenting with fever and rash?
In areas with endemic Rocky mountain spotted fever
70
What steps should be taken for infection control prophylaxis when someone is considered to have meningococcal disease?
All household contacts and anyone having close contact during management of the patient should be treated: ciprofloxacin for adults and rifampin for children.
71
What features do on note on initial evaluation of a child in office for cough?
Any signs of respiratory distress
- Able to talk in full sentences
- incr WOB
72
What conditions are likelier if a cough is dry?
Environmental irritant
| Asthma
73
What conditions are likelier if a child's cough is wet or productive?
lower respiratory infection
74
What conditions are likelier if a child's cough is barking?
Croup
Subglottic disease
Foreign body
75
What conditions are likelier if a child's cough is brassy or honking?
tracheitis
| habit cough
76
What is a "habit cough"?
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
What conditions are likelier if a child's cough is paroxysmal?
pertussis
chlamydia
mycoplasma
foreign body
78
What conditions are likelier if a child's cough is worse at night?
asthma
sinusitis
allergic or vasomotor rhinitis (postnasal drip)
79
What conditions are likelier if a child's cough disappears at night?
habit cough
80
What conditions are likelier if a child's cough is associated with gagging or choking?
GERD
81
Why should you ask for more details when a child or parent reports "wheezing"?
Kids/parents can mean
- wheezing
- stridor
- anything that causes noisy breathing (incl simple congestion)
82
How might a child or parent describe shortness of breath?
Difficulty breathing
Difficulty keep ing up with playmates
Chest tightness
83
What should be reviewed on ROS/assoc Sx for a child with cough?
```
Change in voice
Chest pain
Choking event
Fever
Headaches
Sore throat
```
84
What might a change in a child's voice (with a cough) indicate?
Laryngeal irritation, due to chronic rhinitis or GER
85
What might chest pain in a child with a cough indicate?
Gastroesophageal reflux
| CHF due to myocarditis -- rare, but often missed
86
What might a headache indicate in a child with a cough?
Frontal or orbital headache might be caused by sinusitis
87
True or false: most children with primary TB have severe symptoms.
False: most have few to none -- 50% only found by contact tracing, despite radiologic evidence of diesease
88
What is the most common abnormality on XR in children with primary TB?
Hilar adenopathy
89
What are the presenting SSx of primary TB in infants and toddlers?
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
What is the hallmark of TB (on lung imaging)?
Primary complex:
| Large hilar lymphadenopathy, relative to initial focal lung parenchyma lesion
91
What are allergic shiners?
Darkening of the lower eyelids as a result of venous stasis
92
What is the "allergic salute"?
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
What are Dennie-Morgan lines?
Infraorbital creases that appear due to intermittent edema caused by allergies.
94
How quickly do ICS work?
ICS require several weeks of daily use before the beneficial effects are realized.
95
How is a diagnosis of asthma made?
Clinically + spirometry
In a child <5yo, trial of albuterol instead of spirometry is acceptable (may not be able to cooperate with spirometry)
96
What are the spirometry findings in obstructive lung disease?
Reduction in air flow and increased air trapping (d/t tight airways) reduces FEV1
FEV1/FVC ratio is lower
97
What are the spirometry findings in restrictive lung disease?
Both FEV1 and FVC are lower
FEV1/FVC ratio is normal
98
How are obstructive and restrictive lung diseases differentiated on spirometry?
FEV1/FVC ratio
Low in obstructive
Preserved (normal) in restrictive
99
Why should a spacer be used with inhalers?
Without a spacer, almost all of the medication is delivered to the back of the throat
100
What is PEF monitoring?
Peak Expiratory Flow monitoring
Compares PEF to child's "personal best", an average of PEF over 14d during a period of good control
101
What is PEF monitoring used for?
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
What are the diagnostic criteria of asthma?
Symptoms of recurrent airway obstruction by history and exam
Reversibility (at least partial)
Exclusion of other causes of obstruction
103
What therapy should all pt with asthma have?
Daily prophylaxis with anti-inflammatory therapy (eg ICS)
104
What side effects can occur with ICS?
Side effects are rare
Children on longterm ICS should be monitored for:
- elevation in BP
- blood sugar
- growth delay
- cataract development
105
What treatment strategy can be employed in children with only seasonal symptoms of asthma?
daily use of anti-inflammatory medications (eg ICS), starting several weeks before the expected antigen exposure.
