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by JiGi, Dec. 2014

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Intrauterine factors affecting fetal growth: Maternal factors?	Poor weight gain in the third trimester, poor nutrition, preeclampsia, maternal prescription or illicit drug use, maternal infections, uterine abnormalities, maternal asthma
Intrauterine factors affecting fetal growth: Placental abnormalities?	Placenta previa, placental abruptions or abnormal umbilical vessel insertions may lead to suboptimal fetal growth.
Intrauterine factors affecting fetal growth:Fetal abnormalities?	Fetal malformations (e.g., renal dysplasia or a diaphragmatic hernia), metabolic disease, chromosomal abnormalities (such as trisomy 13), and congenital infections
IUGR: poor wt gain in which TM is a risk factor?	TM3
IUGR: due to fetal abns?	Possible; can see with chromo abns, metabolic dz, congen infxn
What is safe amt of EtOH in preg?	NO SAFE AMT
Smoking ––> what facial abns?	none just low bw
How does cocaine/stimulant affect birth weight? (mxn)	Vasocon ––> placental insuff ––> low bw
What drug: s/e fetal hydantoin syndrome	Phenytoin (see in 30% exposed infants)
Phenytoin: safe in preg? safe in breastfeed?	S/E Fetal Hydantoin Synd (30% exposed fetuses) SAFE IN BREAST FEED
Suspect what etiology: Neonate with: hypoplastic nails & distal phalanges, cardiac defects, cranio deforms, IUGR, M.R.	Phenytoin ––> fetal hydantoin syndrome
Higher risk in young or old moms: –GHTN –Preeclampsia	ADOLESCENT moms ––> low birth wt neonates
All states screen for these two inborn errors of metabolism	PKU, Hypothyroidism
Absolute contraindications to breastfeeding?	Maternal HIV, active maternal drug abuse, infants with galactosemia
Exclusive breastfeeding recommend for how long?	First 6 mo of life, then breastfeeding plus complementary foods until infant at least 12mo
Breastfeeding lowers rates of what?	Diarrhea, acute and recurrent otitis media, UTIs
What does the HEEADSSS inverview of adolescents entail?	H - Home E - Education/Employment E - Eating disorder screening A - Activities/Affiliations/Aspirations D - Drugs (and alcohol, tobacco, and steroids) S – Sexuality S - Suicidal behavior (along with depression and mental health concerns) S - Safety (abuse, fights, weapons, seatbelts, etc.)
Infants born to adolescent mothers are at greater risk for lower birth weight bc…	pregnancy-induced hypertension preeclampsia vertically acquired sexually transmitted diseases
APGAR stands for…	A = Appearance (skin color) P = Pulse (heart rate) G = Grimace (facial expression) A = Activity (neuromuscular tone) R = Respirations (respiratory effort)
When is Ballard exam useful?	if there is no early prenatal ultrasound to help confirm dates, or if the gestational age is in question because of uncertain maternal dates
SGA infants (<10th percentile) have these clinical problems:	Hypoglycemia Hypothermia Hypoxia Polycythemia --> ruddy or red color to skin, respiratory distress, poor feeding and/or hypoglycemia
Topical eye antibiotics for newborns decreases risk for transmission of…	Gonococcal conjunctivitis (NOT chlamydia)
Which measure: Most sensitive indicator of growth abnormalities	growth VELOCITY
EBV: what % 35–40yo infected?	0.95
EBV: infection in adol ––> what % develop mononucleosis?	35–50%
EBV: –fever? –LAD? –sore throat? –how long is incubation?	fever + sore throat + swollen LNs Incubates 4–6w
HIV+ mother ––> what % risk infection (if untreated)?	25–30%
Maternal HIV: increase risk transmission if: –SVD or C/S? –ROM > ___h –what gestation?	SVD ROM >4h <37w
Mother w/unknown HIV risk ––> would you perform newborn screen?	YES
Neonatal HIV: see splenomeg?	possibly
TORCH: what stand for?	Toxo Other: HIV, HBV, parvo, syph Rub CMV HSV–2
Congenital toxo: how screen: –0–6mo –>1yo	0–6mo: infant IgM or IgA >1yo: IgG
Does presence of maternal HBcAb predict risk transmit? HBsAg?	HBcAb: no (could indic past infnx) HBsAg: yes
Next step: presence of HBsAg in mother ––> ?	Give mother AND neonate: 1. HBV vaccine 2. HBIg
Detect via what test: Maternal HIV	PCR
Congenital rubella: how test: –0–6mo –>1yo	0–6mo: IgM 1yo: IgG
Congenital CMV: how detect in neonate? next management step?	URINE CULTURE in weeks 0–3 (if pos ––> routine hearing test)
Which congenital infection: if positive ––> routine hearing test	CMV
CMV: –hearing loss abrupt or progressive? –occurs birth or 1yo?	Progressive Can occur birth OR up to 1yo (continuously monitor)
What dz: Infant w/microcephaly, intracranial Ca2+, lissencephaly, rash	congenital CMV
CMV: –what structure see Ca2+? –in/decrease # gyri? –assoc w/eye findings?	Ca2+ esp in frontal horns of lat vents Lissenceph: decrease gyri, increase cortex thickness Chorioretinitis
congenital CMV: how tx neonate?	Antivirals ONLY IF BABY IS IMMUNOCOMPROMISED
Routine neonate meds: –how admin vitamin K? –Erythro eye drops covers which STD?	IM vitamin K Gonococcus
A mother brings her 20-day-old male infant to your clinic for the child’s first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been vomiting 2 to 3 times per day, and the mother reports that her son seems fussier than her friends’ infants. On exam, you note an eczematous rash and a musty odor to the infant’s skin and urine. Which enzyme deficiency would you expect the infant to display?	PKU A. This infant likely has phenylketonuria (PKU), an autosomal recessive disorder of amino acid metabolism caused by a deficiency in the enzyme phenylalanine hydroxylase. Affected infants are normally detected by newborn screening, but can present with vomiting, hypotonia, musty odor, developmental delay, and decreased pigmentation of the hair and eyes. The best developmental outcomes occur if a phenylalanine-restricted diet is initiated in infancy.
A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks' gestation. The newborn is noted to have dysmorphic cranial features and his head circumference is 28.5 cm (< 5th percentile). What is another associated abnormality you might expect to see in this newborn?	Cardiac Defects B. The mother was on an anticonvulsant for her seizures. Taking anticonvulsants during pregnancy may lead to cardiac defects, dysmorphic craniofacial features, hypoplastic nails and distal phalanges, IUGR, and microcephaly. Mental retardation may be seen. A rare neonatal side effect is methemoglobinuria.
A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis?	Small round blue cells with dense nuclei forming small rosettes (Neuroblastoma) In addition to neuroblastoma, other tumors associated with small blue cells include Ewing’s sarcoma and medulloblastoma, both of which tumors are seen in children.
A 19-year-old female in her 38th week of pregnancy goes into active labor. Shortly after birth her baby is noted to have a high-pitched cry, tremulousness, hypertonicity, and feeding difficulties. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. What is the drug the baby's mother likely used during her pregnancy?	Heroin Opiate use during pregnancy may result in several different symptoms, including CNS findings (irritability, hyperactivity, hypertonicity, incessant high-pitched cry, tremors, seizures), GI symptoms (vomiting, diarrhea, weight loss, poor feeding, incessant hunger, excessive salivation), and respiratory findings (including nasal stuffiness, sneezing, and yawning).
A 19-year-old G1P0 presents in labor to the ED at 38 gestational weeks. On interview it is discovered that the patient had irregular prenatal care, drank a couple of beers every weekend, and smoked 4 cigarettes a day. She delivers a baby boy who is small for gestational age. On exam, it is noted the baby has microcephaly, a smooth philtrum, and a thin upper lip. What do you suspect caused these features in the baby?	Alcohol exposure
Autism screen recommended at these two ages	18mo, 2 years
How long s/p birth: –Colustrum available –Milk available	Colustrum: immed Milk: w/in 40h
Infant WCC: What s/sx is most sensitive indicator of NUTRITIONAL status?	WEIGHT
S/p birth: Neonate feeds how many times in first 24h?	Immed ––> 8–12x
What age: Introduce free H2O?	4–6mo (once taking solid foods)
First days of life: does colustrum meet nutritional reqs?	YES
0–6mo: Does soy formula have enough protein?	yes
Is it safe to combine formula concentrate with water in 1:1 ratio?	YES – if concentrate Never safe to dilute non–concentrated formula to stretch it out
Calorie reqs for infant that is: –term –preterm –very low bw	Term: 100–120 cal/kg/d Preterm: 115–130 Very low bw: 150
Do breast–fed infants req vitamin D? Formula fed?	ALL infants req supp vitamin D ~400 units/day
ALL infants (breast & formula) req what supplement?	Vitamin D
Moro reflex is present at birth and disappears when? What does it detect?	by 4mo Detects peripheral problems (e.g., congenital musculoskeletal abnl, neural plexus injuries)
What age: Introduce solid foods (rice cereal)	4–6mos (IRON–fortified solids) (many premies NOT ready for solids at 4mos)
What age: Eat STRAINED foods (pasta, toast, banana)	9mos
9mo: req how many calories/day? What % from milk/formula?	100 cal/kg/d 75% breastmilk/formula
What age: Infant feeds themselves	9mos
What age: Introduce toast, pasta, banana	9mo
What age: Introduce MEAT	9mo
Infant: how often introduce 1 new food?	q5–7 days start 1 (ID allergies)
Infant: when introduce hot dog?	NEVER – choke
Term infant: Gains how much wt per day?	20–30 g/day
4mo: weights ____x birth weight	2x bw
What age: Weigh 2x birth weight	4mo
What age: Weight 3x birth weight	12mo
1yo: weighs ___x birth weight	3x
<1yo: –# wet diapers per day –# stools per day	6+ wet 6–8 stools
What age: 2x birth LENGTH	4 years
4yrs: ___x birth length	2x length
Red reflex: hold opthalmoscope how far from infant?	10 inches
Red reflex: what 1st see?	at BIRTH
Red reflex present or absent?: Cataracts	Absent
Red reflex present or absent?: Glaucoma	Absent
Red reflex present or absent?: Retinoblastoma	Absent
Red reflex present or absent?: Chorioretinitis	Absent
4 major areas of developmental milestones	Gross Motor Fine motor Language Social/Adaptive
Developmental milestones: 2mo	Gross motor: Lift head -- Head up to 45 deg Fine motor: Follow to midline -- Follow past midline Language: Vocalize -- Laugh Social: Smile responsively -- Smile spontaneously
Developmental milestones: 4mo	Gross motor: Sit w head steady -- Roll over Fine motor: Grasp rattle -- Follow to 180 deg Language: Laught -- Turn to rattling sound Social: Regard own hand
Developmental milestones: 6mo	Gross motor: Roll over -- Sit w no support Fine motor: Reach -- Look for dropped yarn Language: Turn to rattling sound -- Turn to voice Social: Work for toy out of reach -- Feed self
Developmental milestones: 9mo	Gross motor: Stand holding on -- Pull to stand Fine motor: Pass cube (transfer) -- Take 2 cubes Language: Single syllables -- Dada/Mama Social: Feed self -- Wave bye bye
Developmental milestones: 12mo	Gross motor: Stands alone / walk Fine motor: Neat pincer grasp Language: Says dada/mama (specific) and 1 or 2 other words Social: Hands parents a book to read, points when wants something, imitates activities, plays ball with examiner
Hepatitis B: All newborns >2000g get (this) regardless of maternal testing results Newborns whose mothers test positive for HbSAg get (this)	Hep B vaccine = all newborns Hep B Ig = infants at risk for vertical transmission
Vaccines: 2, 4, 6mo	PHHRID PCV Hib, Hep B Rotavirus IPV DTap
Vaccines: 1 year	HaMV Hep A MMR Varicella
Vaccines: 15mo	DIP DTaP IPV PCV
Vaccines: 4yo	DM 4 = DMIV DTaP MMR IPV Varicella
Vaccines: 11yo	Tdap
Why is use of acetaminophen after a vaccine a bad idea?	Acetaminophen can cause lower antibody response for sme immunizations
What is youngest age you administer INFLUENZA?	6mo
Influenza vaccine: The first year of immunization, children <9yo need how many doses and how many months apart? Thereafter, they get annual single dose	2 doses 1 month apart
Immunization S/E: fussy + fever –how long last? –need to see doc?	Commonly last 24h If >24 ––> see doc
What age: Baby sleeps through night	4–6mo
How position in car: <1yo	carseat, middle back seat, face back
How position in car: <10kg	carseat, middle back seat, face back
How position in car: 1–4yo	Carseat, backseat, face forward
How position in car: 4–8yo	Booster, back, forward
How position in car: 8–12yo	Backseat, face forward
SURVEY or SCREEN?: Bright futures	Survey
SURVEY or SCREEN?: PEDS test	Screen
SURVEY or SCREEN?: M–CHAT	Screen
What is name for peds SURVEY most commonly used?	Bright Futures
What age: Laughs, smiles	2mo
What age: Sits unsupported	6mo
What age: Look for dropped item	6mo
What age: Stranger RECOG	6mo (contrast anxiety– 9mo)
What age: Stand w/support	9mo
What age: mama, dada (nonspecific)	9mo
What age: Patty–cake	9mo
What age: STRANGER ANX	9mo
What age: Stands alone	1yo
What age: Mama, Dada – SPECIFIC	1yo (contrast non–specific – 9mo)
Infant screening: do low measures of social/cog & language ––> predict intellectual delays?	YES
What age: Tricycle	3yo
What age: CIRCLE	3yo
What age: Cross	3yo
What age: Knows name, age, sex	3yo
3yo: can draw what shape?	Circle, cross
What age: Knows 2 actions, 1 color	3yo
3yo: knows how many actions? colors?	2 actions 1 color
What age: Toilet training	3yo
What age: Able to eat at table	3yo
3yo nutrition: normal to prefer BLAND foods?	yes
What age: 1st dentist visit	3yo
What age: d/c bottle	1yo
Do developmental surveys alone adequately identify developmental delays?	No
How do developmental assessment services differ for <3yo vs 3-5yo?	<3yo: Early Intervention, dev-behavioral pediatrician, child psych, early learning specialists 3-5: school system
What age: Dresses self, feeds self	3yo
What age: Knows gender and age, friendly to other children, plays with toys/engage in fantasy play	4yo
What age: • Listens and attends • Can tell difference between real and make-believe • Shows sympathy/concern for others	5yo
What age: • Speaks in 2- to 3-word sentences • 75% understandable	3yo
What age: • States first and last name • Sings a song • Most speech clearly understandable	4yo
What age: • Articulates well • Tells a simple story using full sentences • Uses appropriate tenses and pronouns • Counts to 10 • Follows simple directions	5yo
What age: • Knows name and use of cup, ball, spoon, crayon	3yo
What age: • Names colors • Aware of gender • Plays board games • Draws person with 3 parts • Copies a cross	4yo
What age: • Draws a person with > 6 body parts • Prints some letters and numbers • Copies squares and triangles	5yo
What age: • Builds tower of 6-8 cubes • Throws a ball overhand • Rides a tricycle • Copies a circle	3yo
What age: • Hops on one foot • Balances for 2 seconds • Pours, cuts, and mashes own food • Brushes teeth	4yo
What age: • Balances on one foot • Hops and skips • Ties a knot • Has mature pencil grasp • Undresses/dresses with minimal assistance	5yo
What test: Parents answer illustrated 30–item question at designated intervals	Ages & Stages Questionarre (ASQ)
What test: 5 key areas (commun, gross & fine motor, prob–solv, personal/social)	Ages & Stages (ASQ)
Ages & Stages Questionairre (ASQ): –use what ages? –how many Qs? –how long to fill out? –tests what areas?	0–5yo (contrast PEDS – 0–8) 30 Qs 10–15 min 5 areas: communication, gross motor, fine motor, prob–solving, social/personal
Low or high sens & spec: –ASQ –PEDS test	Both high spec & sens
What test: parent answers Y/N/sometimes ––> color–coded score ––> user guide to assess risk	ASQ
PEDS test: –useful what ages? –how many Qs? –what are 2 uses?	0–8 yrs 10q (3 min) uses: 1. Develop screen test 2. Assess parent's concerns
What test: 10 questions ––> use to screen development OR assess parent's concerns	Parent's Eval of Developmental Status (PEDS test)
What test: used in: –0–5yo –0–6yo –0–8yo	0–5: ASQ 0–6: Denver II 0–8: PEDS
What test: Reqs direct observation & parent report	Denver II
Denver II: –use what ages? –tests what areas? –low,mod or high sens & spec for development delay?	0–6yo Tests (4): gross, fine, language, social MODERATE sens & spec
What test: TEACHES developmental milestones	Denver II
What test: Reqs child cooperation ––> time–consuming	Denver II
Premature birth: CORRECTED AGE =	Chronologic age – days/mos prematurity
Rectal exam on infant: –when perform? (what scenario) –what position hold infant?	Only if abd mass; not part of routine Pt SUPINE (on back) ––> flex knees
DDX ASYMPTOMATIC palpable abdominal mass in 2mo?	Hepatic Neoplasm Hydronephrosis Neuroblastoma Teratoma Wilms' tumor (nephroblastoma)
DDX SYMPTOMATIC palpable abdominal mass in 2mo?	Appendiceal abscess CHF (hepatomegaly) Constipation Hepatic abscess
Neuroblastoma in abdomen <1yo: –sympto? jaundice? –how affect G&D?	Asympto, no jaundice May see normal G&D
What dz: Abd CT: heterogeneous, cystic mass with calcifications	Neuroblastoma
Neuroblastoma in abdomen <1yo: 2 sites of mets	Chest LNs Posterior mediastinum
What dz: Small round BLUE CELLS	Neuroblastoma (e.g. abdominal)
Neuroblastoma in abdomen <1yo: How appear tumor cells (histo)	small round blue cells
What dz: Bone marrow ROSETTES	Neuroblastoma
What dz: Tumor cells w/dense, hyperchromic nuclei	Neuroblastoma
Neuroblastoma in abdomen <1yo: How affect CBC?	BM infiltrate ––> ANEMIA, other cytopenia
Neuroblastoma in abdomen <1yo: In/decrease urine HVA:VMA?	INCREASE
What dz: Abdominal mass in infant + increased HVA/VMA	Neuroblastoma
Wilms tumor: see LAD?	NO
Abdominal neuroblastoma: CT appears homo/heterogeneous? cysts?	HETERO CYSTS (hemorrh, necrosis)
Which has more hemorrhage & necrosis: Wilms tumor or neuroblastoma?	Neuroblastoma (appears more cystic on CT)
What dz: Abd mass + heterogenous mass (CT) + PSEUDOCAPSULE	Wilms tumor
Wilms tumor: CT shows demarcation b/w tumor & parenchyma?	YES =pseudocapsule
Wilms tumor: where mets?	PULM (see on CXR) (contrast neuroblastoma – mets to chest LNs & post mediastinum)
Wilms tumor: req BM aspiration?	NO – only if: 1. pain 2. unfavorable tumor histo
Wilm's tumor: affect UA?	Yes – hematuria
Abdominal TERATOMA in infant: common or rare?	RARE
Abdominal teratoma: see jaundice? pallor?	No neither
Hepatic tumor in infant: common or rare? see jaundice? affect G&D?	RARE jaundice decreased G&D
A 9-month old baby boy comes to the clinic for a well child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today’s visit?	Influenza, Hep B, IPV The patient needs a third Hep B, a third IPV, and a yearly flu shot starting at 6 months of age.
You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient?	The developmental milestones mentioned in the vignette are within the range of normal for a 36-month-old child. In the absence of any other evidence of significant impairment, there is no indication for referral at this point.
Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy’s age to be based upon his developmental milestones?	18 months At 18 months, a child should be able to walk backward, and 50–90% of children can run at this stage. An 18-month-old should be able to scribble, build a tower of 2 cubes, have 3-6 words in her or his vocabulary, and be able to help in the house and remove garments.
Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass?	Wilms' tumor Wilms' tumor is commonly associated with Beckwith-Wiedemann syndrome, a genetic overgrowth syndrome. Other features that may be seen in children with this syndrome include omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features.
An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child?	Non-amplification of the n-myc gene is one of the favorable genetics in neuroblastoma.
Eczema / Atopic dermatitis: 2/2 what TWO immune mxns?	1. Increased IgE 2. Dysregulated Ab production (encoded by DIFFERENT gene sets)
Eczema / Atopic dermatitis: Treatment	Topical hydrocortinsone (prescription, not OTC): alternate bw high conc for severe and low conc for minor bouts Antihistamines: -Non-sedating = Loratidine, Cetirizine -Bedtime only = Diphenhydramine, Hydroxyzine
DDX for Eczema?	Psoriasis: rare in children Seborrhea: Cradle cap in infants
More more than how many oz of juice per day?	4-6oz
Enlarged thyroid common or rare in child?	RARE
Enlarged Lymph Nodess: –common or rare in toddler? –non/tender? –shotty located in what areas?	Common NT Shotty in ANT & POST cervical
Murmur in toddler: –most non/fxnl?	FUNCTIONAL
NEW murmur: common due to congen heart disease?	No ––rarely 2/2 congen
Most common abdominal mass in children?	Stool
In–toeing in toddler: commonly due to what anatomic variant?	Tibial torsion
Tibial torsion in toddler: leads to what type of gait?	IN–TOEING
How to correct in-toeing in todder?	Most spontaneously resolve by 8yo (refer to orthopedist if not resolved by 4yo) Walking strengthens leg mm and allow correction
MCC nonspecific vulval erythema in female toddlers?	Poor hygeiene once they are toilet training and caring for themselves in bathroom
When to do anemia screening?	12mo and before entering preschool/kindergarten Correlates with period where diet is most in flux and iron may be deficient
Anemia in 3yo: #1 etio	Iron–deficiency 2/2 malnutrition Less common causes: chronic GI blood loss due to food allergies, gluten enteropathy
Anemia in 3yo: Is anemia itself a good predictor of Fe2+ deficiency?	NO –– poor predictor of iron def in diet
HIV in infant: expect anemia?	YES (ACD)
First test if suspect possible anemia in toddler?	Fingerstick Hemoglobin/Hematocrit CBC is more test than needed for now Lead screening was done when child was younger and putting everything in his mouth
What dz: Microcytic anemia with decreased RDW	thalasemmia, sickle cell dz
Micro/normo/macro anemia: –SCD –Thal	Both MICRO
Mild (>9) or severe (<9) anemia: Aplastic anemia	severe
Mild (>9) or severe (<9) anemia: Folate deficiency	severe
Mild (>9) or severe (<9) anemia: B6 deficiency	Severe
What 3 nutritional defs can cause anemia?	Iron Folate B6
3yo w/IDA: req iron supplement OR can just encourage iron–rich foods?	Give Fe2+
INITIAL labs in anemia w/u: –retic? –smear?	YES
INITIAL labs in anemia w/u: –stool blood? –UA?	YES
Iron–def anemia: –micro/macro? –hypo/hyperchromic? –DEC/INCREASED retics?	Micro, hypo DECREASED RETICS
Hemophilia A or B: Decreased VIII	A
Hemophilia A or B: Decreased IX	B
Hemophilia A: what def?	Decreased VIII (8)
Hemophilia B: what def?	Decreased IX (9)
Hemophilia: how affect: –PTT –Bleed time	PTT: prolonged Bleed time: normal
What dz: Prolonged PTT, normal bleed time	Hemophilia
How inherit: Hemophilia	X– RECESSIVE
A 5-year-old girl comes into your office for a well-child visit. The mother says that child is overall very healthy, but she highlights “occasional colds” and recently more frequent temper tantrums. She does well in preschool, is toilet trained, and enjoys eating mostly pasta, bread, and milk. She lives with her mother and father in a home built in 1985. Lab studies were significant for a mild anemia with a hemoglobin of 10.0 g/dL. You note that her hemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anemia?	Iron deficiency Given the patient’s age and preference for pasta and milk, the most likely cause of anemia would be iron deficiency. Treatment would include oral iron supplementation and increased dietary iron intake.
A 3-year-old boy presents for a follow-up visit after being diagnosed with iron deficiency anemia. He is currently receiving oral iron supplements, 2 mg/kg of elemental iron daily. He has a dietary history of eating mostly sweet, bland, low-texture foods. What strategies may be used to improve his diet?	Gradually introduce new foods and slowly decrease his old favorites This choice is correct, because gradually introducing new foods and slowly decreasing his old foods will likely ease the transition to healthier diet choices and encourage long-term adjustment.
A 2-year-old girl is examined as an outpatient. While waiting for the pediatrician, her mother reads her a short book. When they are done, her mother asks her to take the book and return it to a bookshelf in the room. The child is not able to hold a pencil and cannot write her name. She can kick and throw a ball, but cannot jump in place. Which of the following best describes this child’s development?	Age-appropriate development
At a routine well-child visit, the frantic mother of your 4-year-old male patient states that she thinks her son has some developmental delays based on what she hears from other parents. Although he knows how to do such things as throw a ball and copy a circle, he cannot brush his teeth on his own, tie his shoes, or hop on one foot. According to the AAP’s Bright Futures, which of the following are development milestones for typical 4-year-olds?	A a normally developing 4-year-old should be able to hop on 1 foot, copy a cross, pour/cut/mash their own food, and brush teeth
A 3-year-old boy described by his mother as a picky eater comes in for a regularly scheduled well-child visit. His mother complains that he has had less energy than usual for the past few months. There is a high clinical suspicion he is anemic. Which of the following is most correct?	The most likely cause of anemia in the question is picky eating resulting in low iron intake, which would cause microcytic anemia. A girl with menometrorrhagia would present with iron deficiency and her MCV would be indicative of microcytic anemia.
3yo: limit how many meals & how many snacks?	3 meals, 2 snacks
How determine: WEIGHT AGE	Age at which wt plots @ 50%
BMI =	Kg/m2
BMI: what # and %tile: –overweight –obese	Over: 25–30 (85–95%) Obese: >30 (>95%)
Predispose to UNDER or OVERweight: Bardet–Biedl syndrome	Over
Predispose to UNDER or OVERweight: Cohen syndrome	Over
Does high birthweight correl w/childhood obesity?	YES
What % of 6–19yo are obest?	0.15
Childhood obese: assoc w/SES?	Yes –– low SES
What % will become obese adults?: –obese 4yo –obese adolescent	4yo ––> 20% obese adults adol ––> 80% obese adults
What is increased risk that child will be obese: –1 obese parent –2 obese parents	1: 3x 2: 10x
Under 3yo: which is stronger predictor of obesity in adulthood: Child's current wt OR parental obesity	Parental obesity
Early adolescence: normal to see dec/increase insulin sensitivity?	Adol ––> DECREASE insulin sensitivity (i.e. normal to see transient insulin resistance) ––> increase wt gain
What fraction of obese children are hypertensive?	1/3 of children with BMI>95th %ile 9x more frequent in overweight kids
Obesity: assoc with restrictive lung disease? reactive?	Restrictive (inc Obstructive Sleep Apnea, Pickwickian Syndrome) NOT assoc w/reactive airway disease
Obesity: GI associations?	Non-alcoholic steatohepatitis Gallbladder disease
Obesity: assoc w/Blount disease?	YES (outward bowing of tibia)
What dz: Widening of physis (hip x–ray)	SCFE
SCFE: wide or narrow physis?	WIDE
SCFE: displace what 2 components of femur?	HEAD & NECK (thru physeal plate)
What dz: obese kid w/delayed sex maturation & antalgic gait	SCFE
SCFE: see limited INT or EXT rotation of hip?	limited INTERNAL rotation
Order what labs: obese child with: –85–95%, no risks –85–95%, risks –>95%	Order what labs: obese child with: –85–95%, no risks: fasting lipids –85–95%, risks: ALT, AST, BG –>95%: BUN, Cr
Obese child: how tx: –85–95% >95% in pre–teen, teen	85–95: slow wt GAIN (until <85%) 95: active wt loss (gradual) Pre: <1lb/mo Teen: 1 lb/WEEK
Obese child: –limit TV hrs? –amt exercise	TV <2h Exercise: 60min every day
Obesity + low HDL + high triglycerides = ?	Metabolic Syndrome
If child has HIGH INSULIN level… check: (85-95th %ile + no risk factors) --> ? (85-95th %ile + risk factors) --> ? (>95th %ile) --> ?	(85-95th %ile + no risk factors) --> Fasting Lipid Profile (85-95th %ile + risk factors) --> FLP + Hepatic Transaminases + Fasting Glucose (>95th %ile) --> FLP + Hepathic Transaminases + Fasting Glucose + BUN + CREATININE
A2DM: Up to 1/3 of children with Type 2 DM are accidentally diagnosed. How?	UA --> ketones in urine
Childhood DM: inc/decrease appetite?	INCREASE (polyphagia)
What # to dx DM: –Random BG –Fasting –2h OGT ––Which method preferred to dx DM?	Random: >200 Fast: >120 2h OGT: >200 FASTING PREFERRED
DM: screen ALL overweight children? when start screen (2 options)? screen how often?	Screen if: overwt (85th %ile) + 2 (Fhx, sxs, etc) Start 10yo OR puberty onset Screen q2 years
How define NORMAL BP in child?	Both SBP & DBP <90% (age/gender/ht/wt)
What age: Start routine BP check	3yo
Name for: SBP & DBP: –90–95% –95–99% –>99%	90–95%: pre–hypertension 95–99%: stage I HTN >99: stage II
What % SBP & DBP: Pre–hypertension	90–95%
What % SBP & DBP: Stage I HTN	95–99%
What % SBP & DBP: Stage II HTN	>99%
Increased BP in >6yo: mcc due to 1' or 2' HTN? Important correlate?	PRIMARY, assoc. with obesity
What dz: Young child with HTN + no family hx HTN	Coarctation of Aorta, renal parenchymal disease
Early menarche vs. Delayed puberty -- which assoc with BMI > 85th %ile?	Early Menarche
Childhood HTN: damages which heart chamber?	LVH
ADHD: sxs for how long? # settings?	6+ mos and before 7yo 2+ settings
ADHD: req how many sxs (inattn or hyper)?	6+ (either type)
How distinguish inattention ADHD from sleep disorder (e.g. Obstructive Sleep Apnea)?	Sleep: decreased sleep & tired ADHD: poor sleep but NOT over–tired
MDD in child: high rate of converting to what psych condition?	MANIA / Bipolar Disorder (looks like hyperactivity so can mimic/accompany ADHD)
ADHD: assoc w/oppositional defiance disorder? conduct disorder?	BOTH
ADHD: how tx? (1 drug; know dosing)	Sustained–release methylphenidate (concerta) 18mg po bid BIDBIDBID
George is a 7-year-old boy frequently in trouble at school for being disruptive and inappropriately talkative in class, not following directions set by his teacher, and not working well with classmates during group activities. His mother relates that at home George is always on the go, sleeping only 6 to 7 hours a night. He does not follow her rules all the time either, including not doing his homework, and sometimes putting himself in danger by doing things she tells him not to do, such as running away unaccompanied. Which of the following is the most likely diagnosis?	ADHD ADHD is characterized by the triad of impulsivity, hyperactivity, and inattention. Other symptoms include motor impairment and emotional labiality. ADHD is typically diagnosed before the age of 7 but persists into adulthood. Intelligence is usually normal, but individuals with ADHD commonly perform more poorly academically than would be expected for their IQ.
An 8-year-old boy is brought to clinic by his parents because they are concerned that he has not been doing his homework. His teacher recently called the parents to say that their son seems distracted in class, constantly interrupts other children when they are speaking, and is very fidgety. When you speak with the boy, he tells you that he did not know about the homework assignments and that he tries hard to pay attention in class. What is the next best step in management?	Contact the teacher to find out more about his behavior. Find out more about the child's behavior at home Contacting the teacher to find out more about the child's behavior at school and learning more about his behavior at home are the best ways to determine if 6 of the symptoms are present in 2 or more settings, which is required to make the diagnosis of ADHD. It also will be important to learn more about other aspects of this child’s life, as there are several factors that can lead to acting out (including learning disability, hearing disability, family stress, and abuse).
An 8-year-old healthy obese African American male with no past medical history is found to have a blood pressure of 125/90 mmHg on all four extremities on routine evaluation during an office visit for well-child care. Review of symptoms is negative. A physical exam and screening bloodwork are performed. Both are normal, with the exception of his blood pressure and obesity. What is the most likely diagnosis?	Primary Hypertension The sole physical finding is hypertension. Given the mild hypertension and the patient’s age, symptoms are unlikely to be present. Other etiologies should be ruled out, but review of symptoms, physical examination, and laboratory studies do not suggest other etiologies.
Billy, a 7-year-old boy, presents to the clinic with complaints of headaches and episodes of feeling sweaty and flushed. He also reports that at times he feels as if his heart is racing. Billy was full term, had an uncomplicated birth, and has been otherwise healthy until now. On exam his BP is 120/80 mmHg and is the same in his upper and lower extremities. His weight and height are in the 50th percentile for his age. What is a likely cause of Billy’s hypertension?	Catecholamine excess (pheochromocytoma or neuroblastoma) should be suspected in a child who is hypertensive and has episodes of sudden sweating, flushing, or feels that his heart is racing. Billy is exhibiting these signs and a urine catecholamine testing would be appropriate in this case.
Jane is an 8-year-old girl who presents to your clinic for follow-up after being hospitalized for status asthmaticus. She has just completed a 10-day course of systemic steroids. Given her history of moderate persistent asthma, her outpatient regimen includes Advair, a combined steroid and bronchodilator. She was also diagnosed with ADHD one year ago and was started on Concerta, 18 gm PO once a day. Her BMI today is at the 83rd percentile for her age, and her blood pressure is at the 98th percentile for her age. What is the most likely cause of her stage I hypertension?	Medications Both steroids and amphetamines can cause increases in blood pressure, especially when used in combination. Steroids increase blood pressure by mimicking endogenous cortisol and the sympathetic fight or flight response. Amphetamines mimic norepinephrine, stimulating alpha and beta adrenergic receptors, causing an overall increase in blood pressure.
Pedigree: try to get how many generations?	3rd
How inherit: Marfan	AD (DOM!)
How inherit: neurofibromatosis	AD
How inherit: Duchenne's Musc Dys, Hemophilia	XR
How inherit: MELAS	Mitochondrial (inheritedfrom mother --> all children can be affected. Affected males will NOT have affected children)
How inherit: CF	AR
How inherit: Tay–Sachs	AR
Physical findings in order of appearance of eating disorders	1. Weight loss / failure to gain 2. Amenorrhea (in females) 3. Bradycardia --> postural hypotension 4. Electrolyte abnormalities
Puberty: order of things for girls vs. bodys	Girls: Breast bud (10/11), pubic hair (10/11), growth spurt (12), menarche (12/13), adult height (15) Boys: growth of testicles (12), public hair (12), penis growth (13/14), growth spurt (14), adult height (17)
What Tanner Stage: Testes <1.5 mL	1
What Tanner Stage: No pubes	1
What Tanner Stage: Testes 1.6 – 6 mL	2
What Tanner Stage: Red, thin scrotum	2
What Tanner Stage: Thin pubes at base of penis	2
What Tanner Stage: Testes 6–12 mL	3
What Tanner Stage: Curly, coarse hair	3
What Tanner Stage: Testes 12–20	4
What Tanner Stage: Darken & increase size of scrotum	4
What Tanner Stage: Adult pubes but absent on thighs	4
What Tanner Stage: >20 ml testes	5
What Tanner Stage: Pubes on medial thighs	5
Delivering bad news: is it OK to TOUCH pt?	YES
Teen interview: should you set up expectation for interview at beginning?	Yes
Teen: start with specific OR open–ended questions?	SPECIFIC
Teen interview: if parent refuses to leave ––> should you advocate for adolescent privacy?	Yes
T/F offer HIV test to ALL sexually–active >13yo	TRUE
Normal range puberty: –F –M	F: 8–13yo M: 10–15yo
Tanner staging: assess what 2 features (M, F)?	M: pubes, testes F: pubes, breasts
Name for: Measure of BODY COMPOSITION	anthropometry
Cause of anemia in teenage female?	heavy periods
Bleeding disorder suspected in teenage female with fatigue?	vWD
In addition to menorrhagia, other symptoms of vWD in teenage female with fatigue?	ecchymoses, epistaxis, bleeding s/p tonsillectomy or dental extraction, gingival bleeds, abnormal bruising in non-expose areas (butt, back, trunk)
Other than bleeding disorder (vWD), another cause of fatigue in teenage female?	Hypothyroidism
Symptoms of hypothyroidism?	cold skin, slowness, fatigue, prefer hot weather to cold, doing poorly in school, menorrhagia, shorter menstrual cycles
How inherit: vWD	AD
What dz: –prolonged PTT, normal bleed time –prolonged bleed time, normal PT	HemoPhilia: prolonged PTT, normal bleed time vWD: prolonged bleeD time, normal PT
vWD: how inherit –Type I –II –III	I&II: AD III: AR
vWD: what is defect in: –type I –II –III	I: decreased vWF (mild) II: QUAL defect III: undetectable vWF (severe)
vWD: which TYPE? Decreased vWF; MILDEST	I
vWD: which TYPE? Most common (70%)	I
vWD: which TYPE? inherited AR	III
vWD: which TYPE? QUAL defect	II
vWD: which TYPE? Undetectable vWF	III
vWD: which TYPE? Most severe	III (undetectable vWF)
vWD: how tx?	Intranasal OR IV desmo
What dz?: Tx w/intranasal or IV desmopressin	vWD
A 15-year-old female comes to the clinic with a chief complaint of feeling tired for one month. She has also been complaining of frequent nosebleeds while at school and bruising easily. When further history is elicited, you find out that menarche was at the age of 9 and her periods have always been heavy and irregular. Her mother and grandmother also have histories of heavy periods and easy bruising. You suspect a bleeding disorder and send off some labs including a CBC, INR, PT, PTT, and a von Willebrand panel to confirm your diagnosis. Your suspicion was correct for the most common type of bleeding disorder. How is this bleeding disorder most commonly inherited?	AD In AD disorders males and females are equally affected within each generation. These include conditions such as von Willebrand’s disease, Marfan syndrome, neurofibromatosis, and Huntington’s disease.
A 14-year-old girl presents to your office wondering why she has not had her period yet. Her mother states that she and the patient’s grandmother reached menarche at 13 years of age. The patient is concerned she is behind her friends in terms of development. She is doing well in school and has not had developmental problems in the past. On physical examination, her breasts are elevated without a secondary mound, and curly, coarse pubic hair is present on the labia majora in a triangular shape but does not reach the mons pubis. What Tanner stage would you assign this patient?	Tanner Stage 3 The patient in the vignette is at Tanner Stage III of development. Her breast buds are elevated but do not have the secondary mound characteristic of Tanner Stage IV. Her pubic hair distribution extends more laterally than Stage II but is not adult-like in hair quality and does not extend onto the mons pubis.
A 16-year-old female presents to clinic complaining of worsening fatigue. Family history is significant for hypothyroidism and heavy periods in the grandmother. Her exam reveals mild tachycardia and oozing around a recent piercing, but is otherwise normal. Labs reveal Hgb 8.5 g/dL, MCV 58, PT 12.5, PTT 44, and low von Willebrand factor activity. Which of the following is the most appropriate treatment for her underlying disorder?	Desmopressin Von Willebrand’s disease is the underlying cause of this patient's anemia, as indicated by the low von Willebrand factor activity. This is the most common hereditary bleeding disorder, occurring in roughly 1% of the population. Intranasal or intravenous desmopressin is appropriate treatment for most bleeding problems. Desmopressin works by causing release of von Willebrand’s factor from vessel endothelial cells.
A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in what order she should expect to see normal developmental changes in her daughter. Which of the following sequences is correct?	breast bud -> pubic hair -> growth spurt -> menarche breast buds are the first sign (10–11 years), followed by pubic hair (10–11 years), then a growth spurt (12 years), and then menarche (12–13 years). Most girls reach adult height by approximately 15 years.
Frank is 16-year-old male brought in by his mother who complains that her son “looks much younger than his age.” She states that until about four years ago, she did not notice much difference between Frank and his friends. However, in the past two years, Frank has become the shortest person in his class. Frank's mother is concerned that he has a “hormone problem” and wants to know how she can tell if he has begun puberty. What is usually the first sign of puberty in a male?	Testicular enlargement The first sign of puberty in a boy is testicular enlargement. The onset of puberty is quite variable, but usually occurs between 10 and 15 years for boys. It is rare for boys not to have begun puberty by the age of 16. To assess whether or not a male has entered puberty, one must know the order of the appearance of secondary sexual characteristics.
What does mnemonic OPQRSTAAA to assess pain stand for?	O = Onset P = Position Q = Quality R = Radiation S = Severity T = Timing A = Aggravating factors A = Alleviating factors A = Associated symptoms
DDX for chest pain	Precordial catch syndrome Musculoskeletal / costochondritis GI/GERD Cardiac Respiratory/asthma
#1 sudden death adol athlete	Hypertrophic Obstructive Cardiomyopathy (HCOM)
Hypertrophic Obstructive Cardiomyopathy (HCOM): –p/w what sx? –what % have abn EKG?	SYNCOPE 90% abn EKG
Child w/chest pain: higher suspicion of CARDIAC vs chest wall pain etiology if: present at rest OR exercise only?	Exercise only
Chest pain due myocardial ischemia: –sharp or dull? –how long last?	Dull pressure 10–20 mins
What dz: Sharp/stabbing chest pain REPRODUCIBLE w/direct sternal pressure	Costochondritis
Costochondritis: how long does pain last?	few seconds of stabbing over hrs–days
Costochondritis: chest pain assoc w/exercise?	NO – sporadic
What is dz: Chest pain worse with deep inspiration	Costochondritis
Costochondritis: worse with insp or exp?	Deep insp
Which more common: Precordial catch OR costochondritis	Precordial catch
#1 chest pain in child	Precordial catch
Precordial catch: assoc w/exercise?	No (occurs equally at rest or exercise)
Precordial catch: –diffuse or well–localized? where most common? –sharp or dull?	sharp, well–localized at LOWER STERNAL BORDER
Precordial catch: how long pain last?	secs–mins
Precordial catch: worse w/insp or exp?	Deep insp (same as costochondritis)
What dz: Chest pain that pt can BREAK with forced deep insp	Precordial catch
Costochondritis or Precordial catch? Pain due to inflammation, usually follows a recent viral infection, muscle strain, trauma, or overuse	Costochondritis
Name for: Inadeq cerebral BF ––> transient LOC & loss of postural tone	Syncope
Syncope: underlying mxn?	Decreased cerebral BF
3 general etios of syncope in child	1. Neurocardiogenic (vasovagal; #1) 2. Neuropsych (szs, orthostatic, drugs) 3. Cardiac (arryth, structure defect)
Syncope 2/2 orthostatic hypotension: classify as NEUROPSYCHIATRIC or CARDIOGENIC?	Neuropsychiatric
What drug class: S/E prolonged QT ––> neuropsychiatric syncope	Antihistamines
Antihistamines: S/E what EKG change?	Prolonged QT
Difference b/w 1' and 2' cardiac syncope	1': structural defect ––> obstruct ventricular outflow 2': ventricle DYSFXN or ARRYTH
3 types of arryths that can cause syncope	1. SVT 2. VT 3. Heart block (2/2 Lyme)
Syncope in child: EKG which pts?	ALL
Syncope in child: which is more serious: Pallor OR warm/flushed skin	WARM/FLUSHED
Syncope during exercise: mandatory refer to cardio?	YES
Are murmurs COMMON in healthy adols?	Yes
Teen physical: Palp which 2 pulses?	Femoral Radial ––> assess Ao coarct
HCM: murmur louder supine OR standing?	STANDING
Murmur: evaluate if louder than ___ (what grade?)	III/IV
Teen physical: How long should orthopedic exam take?	2min
Teen physical: Require chaperone for GU?	always
Adolescent immunization: Do teenagers get Tdap or DTaP?	Tdap…both contain Tetanus, diphtheria, and pertussis Tdap is a booster. DTaP for children has 3-5x more diphtheria toxoid than adult Tdap
Meningococcal vaccine: First dose at what age? Booster dose at what age?	First dose - 11/12 Booster - 16yo If first dose is at 13-15, give booster 16-18
HPV vaccine: First dose at what age? What is dosing schedule? Which type for girls vs boys?	11/12yo --> 2mo after dose #1 --> 6mo after dose #1 Girls: HPV2 --> cervical cancer Boys: HPV4 --> genital warts, anal cancer
John is a 17-year-old presenting today for a pre-participation physical exam. During the interview, he reports a low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a temperature of 101.3° F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His participation would be most likely affected by which of the following tests?	EBV serologies This choice is correct because the patient’s symptoms are suggestive of infectious mononucleosis. These include complaints of low-grade fever and malaise and findings of cervical lymphadenopathy and pharyngeal exudate. If testing is positive, the patient should be restricted from strenuous activity or contact sports during his illness due to the risk of splenic rupture.
A 17-year-old boy presents for a sports pre-participation physical. He reports that he occasionally gets short of breath and feels light-headed with exercise, and sometimes he experiences chest pain as well. He lost consciousness once last season during a playoff basketball game, but attributed it to feeling sick at the time. His grandfather died suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis?	Prolonged QT Prolonged QT syndrome can cause syncopal episodes in late childhood or adolescence. QT intervals are elongated on ECG and lead to arrhythmias, like ventricular fibrillation. This condition is often associated with other abnormalities, including severe congenital sensorineural deafness.
A 16-year-old male presents to your office requesting clearance to play football. You begin by taking his medical history. He says that he feels very well, but admits that he recently experienced one episode of syncope that occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while playing basketball. Physical examination reveals no abnormalities. What is the next best step in management?	ECG and referral to Cardiology Referral to cardiology is the absolute next best step! The combination of syncope with exertion and a family history of a young death is concerning for something like hypertrophic cardiomyopathy. Don’t be fooled about heat stroke. That is a positive family history for sudden death in a young person. This patient must be evaluated by cardiology, even if you don’t hear a cardiac murmur!
A 16-year-old previously healthy male comes to the Pediatrics Urgent Care Clinic having “almost fainted” at soccer practice. He says that he had not eaten much earlier in the day and it was very hot and muggy outside. He felt light-headed and sick to his stomach. He denies losing consciousness and did not fall to the ground. He denies any chest pain. When you examine him, his eyes are sunken and he is tachycardic. What would be your next step in his management?	Give fluids and recheck vital signs The patient is likely dehydrated given the dizziness without loss of consciousness in the setting of poor PO intake, hot weather and exercise. As the symptoms occurred while he was upright, the likely mechanism is vasovagal. His sunken eyes and tachycardia are signs of moderate to severe dehydration. Since this is a clinical diagnosis, fluids should be given with subsequent rechecking of heart rate and blood pressure to confirm the diagnosis.
Claire is a 16-year-old female who presents for birth control management. Her review of symptoms is unremarkable except for chest pain. When you ask her more questions, she reveals the pains are intermittent, on and off for the past couple months. It is not associated with exertion, sharp, and well localized at the left sternal border. It is very brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in. She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and physical exam are normal. Which is the next best step in management?	Reassurance Based on the history, and assuming your physical exam is unremarkable, this sounds most suggestive of precordial catch syndrome, the most common cause of chest pain in an adolescent. No further workup is needed.
For infant of a diabetic mother (IDM), incidence of major malformations is directly related to what level in first trimester?	Hemoglobin A1c A1c > 12 --> 12x increase in major malformations
High levels of Insulin in 3rd trimester results in overgrowth of which fetal organs?	Insulin sensitive organs: Heart, Liver, Muscle (insulin-INsensitive organs NOT oversize: brain, kidneys)
Which is more predictive of LT neuro outcomes: Umbilical artery blood sample OR APGAR	Umb art
Perinatal asphyxia: detect via sampling which blood vessel in cord?	Umb ARTERY ––> detect hypoxia, acidosis (NOT vein)
GDM: predispose neonate to: –hypo or hypergly? –hypo or hyperCa?	Hypogly (due increased insulin) HypoCa2+
GDM: is neonate at increased risk of resp distress?	YES
Fetal glucose: normally what fraction of maternal glucose?	2/3 maternal glucose (glucose crosses placenta)
GOAL BLOOD GLUCOSE IN NEONATE	41–50
DDX newborn with respiratory distress	Respiratory distress syndrome --> ↓ surfactant Transient tachypnea of the newborn --> delayed lung clearing CHF --> heart defect, w/murmur Sepsis/Pneumonia --> poor feeding, lethargy; PROM, GBS Hypoglycemia --> in IDMs Less likely: Cong. Diaph. Hernia --> bowel sounds in chest Pneumothorax --> gas in pleural space, no breath sounds on one side Meconium Aspiration --> Fetal grasping in utero Transp. of GA --> severe cyanosis at birth Hypothermia --> assc w sepsis Coarc. of aorta --> LV outflow obstruction
Persistent pulmonary HTN of newborn: –underlying etio –where does blood divert?	Due elevated pulm vasc R Blood diverts through ductus arteriosus & PFO (bypasses lungs)
Persistent pulmonary HTN of neonate: presents with tachy/bradycardia?	Tachy (also tachypnea)
Cyanotic newborn: order an O2 challenge test?	YES --> cardiac vs. pulm etiology
Acrocyanosis at birth: –usu resolves after how long? –when start to suspect congenital HD?	Usu resolves 4–5h After 8h warming ––> suspect congen HD
#1 etio respiratory distress in preterm	Resp Distress Syndrome (RDS) aka Hyaline Membrane Dz
Respiratory Distress Syndrome in neonate: underlying etio	Surfactant deficiency
Name for: Neonatal dz caused by surfactant deficiency	Respiratory distress syndrome
Respiratory Distress Syndrome in neonate: –genetic component? –M or F? –C/S or SVD?	More common if siblings w/RDS M > F C/S w/out labor > SVD
Respiratory Distress Syndrome in neonate: If mother has GDM ––> may see RDS in infant up until how many weeks gest?	37
Neonatal with resp distress: which is more common if healthy mother and gest >34w: RDS or transient tachypnea of newborn	TTN
How distinguish (what test): RDS vs. TTN	CXR RDS: air bronchograms, ground glass
What dz: Newborn with resp distress & CXR w/bronchograms & ground glass	RDS
Transient tachypnea of newborn: More common term or preterm?	TERM !!!!
Transient tachypnea of newborn: Underlying etio	Delayed fluid clearance
Transient tachypnea of newborn: Early or late onset? Mild or severe distress?	Early onset, mild distress
Transient tachypnea of newborn: –M or F? –C/S or SVD? –micro or macrosomy	M > F (same as RDS) C/S (same as RDS) MACROSOMY (esp DM)
What dz: Neonate w/resp distress & CXR w/perihilar streaking, coarse densities and WET LOOKING lungs	TTN (contrast RDS: bronchograms, ground glass)
TTN or RDS: Male	BOTH
TTN or RDS: Perihilar streaking	TTN
TTN or RDS: Fluffy densities	TTN (contrast RDS: ground glass)
TTN or RDS: Lateral view shows fluid in pleural space, fissures	TTN
TTN or RDS: WET LOOKING LUNGS	TTN
Pneumothorax: More common in premie?	YES
Neonatal sepsis/PNA: assoc w/PROM?	Yes – may have subtle early findings like poor feed, lethargy
Meconium aspiration: occurs when in birth process?	In utero OR 1st breath
TTN: expect to resolve after how long?	12h
If suspect TTN but respiratory sxs do not improve, suspect WHAT? Next steps?	Suspect Pneumonia Order repeat CXR, Start antibiotics
APGAR: –how many categories? –points?	5 categories – appear, pulse, grimace, activity, resp 2pts each
Are low 1– & 5–min Apgars markers of intrapartum hypoxia?	NO – not conclusive
Which is better predictor of neonatal death: 1– or 5–min apgar	5–min (although best is umb art sample)
What birthweight #s: Extremely low bw	<1,000 g (contrast very low: 1k – 1,499)
What birthweight #s: Very low bw	1,000–1,499
What birthweight #s: Low bw	1,500 – 2,499 (contrast very low: 1,000–1,499)
What birthweight #s: NORMAL	2,500 – 4,000
Ballard score: estimates what? includes what criteria?	Gestational age (s/p birth) Criteria: neuromuscular & physical maturity
Dubowitz exam: what 3 categories?	Estims gestational age (alternative to Ballard score; older tech) 1. Preterm (<37w) 2. Term 3. Post (>42)
Cephalohematoma: 2/2 what device?	VACUUM
If baby is LGA ––> risk hypo or hypergly?	HYPO (same if baby is SGA ––– inadeq glycogen stores)
If baby is SGA ––> risk hypo or hyper gly?	Hypo (2/2 low glycogen store) Same if baby is LGA (2/2 overproduction of insulin)
SGA neonate: expect pale or ruddy?	RUDDY ––– due polycythemia ––> increased viscosity
Premature infant: do you need to establish breast–feeding before discharge?	YES (risk hypothermia, decreased glycogen stores)
Newborn: Is 1st phys exam (at birth) a good indication of successful transition to extrauterine?	YES
Newborn: 1st breath ––> where does fluid in lungs go?	Squeezed out (cxns, air) ––> absorbed by PULMONARY LYMPHOCYTES
0–1h life: normal V/S: –pulse –rr	p 160–180 rr 60–80
2h life: normal V/S: –pulse –rr	p 120–160 rr 40–60
2h neonate: suspect resp distress if RR > ____	rr > 60 Also: use of accessory muscles (nasal flaring, intercostal retractions, grunting), hypoxia, hypercapnia
Neonate: Use glucometer to confirm hypogly?	NO – use to SCREEN (NOT confirm)
Neonate glucometer read: If neonate BG <40 –––> what is next step?	Meas serum BG (to confirm neonatal hypogly) START TX WHILE WAITING
Neonate glucometer: Start tx if neonatal BG < ___	<40
If neonate with RDS ––> order what 3 tests?	1. CBC w/diff , CSF cx 2. Blood cx 3. LP --> r/o Sepsis
Tx hypoglycemic neonate if: –symptomatic and BG <___ –asympto and BG <___	sympto & <45 asympto & <35
Hypoglycemic neonate: how tx?	5% dextrose in WATER ––> then feed breast/formula (prevent rebound hypogly) ––> monitor until BG > 40 & stable If no respond H2O ––> IV dextrose
Adam is a 2-hour-old infant born at 32 weeks' gestational age via NSVD to a healthy mother with negative group B streptococcus status. There was no premature rupture of membranes and no meconium in the amniotic fluid. His Apgars were 8 at one minute and 9 at five minutes. Over the last two hours he has become progressively tachypneic. On physical examination he is large for gestational age. His vital signs are respiratory rate 75, temperature 36.5 C and heart rate is 130 beats per minute. His lung exam is remarkable for intercostal and subcostal retractions, grunting, and equal breath sounds. His heart exam reveals normal rhythm, normal S1 and S2, no murmurs, and normal peripheral pulses and capillary refill. Which of the following is the most likely cause of the patient’s condition?	Respiratory Distress Syndrome Respiratory distress syndrome (RDS) causes tachypnea and is therefore an important consideration in this case. RDS is more common in premature infants. Given the lack of history of maternal diabetes, an NSVD birth, and few risk factors for sepsis other than prematurity, Adam is likely to have RDS. Transient tachypnea of the newborn (TTN) is much more common in infants born to diabetic mothers. TTN is unlikely because he is 32 weeks, very premature, and was born via NSVD. RDS is much more likely, although TTN is still a possibility and would need to evaluated with a CXR.
A 3-hour-old infant boy, born by C-section at 36 weeks to a 30-year-old G1P1 with Apgars of 8 and 9 at 1 and 5 minutes, respectively, is found to be tachypneic in the newborn nursery. His mother has a history of Type II diabetes that was poorly controlled during her pregnancy. She was compliant with prenatal vitamins and took no other drugs during her pregnancy. Prenatal labs, including GBS, were negative. The mother’s membranes ruptured 9 hours prior to delivery, she was afebrile, and the amniotic fluid had no meconium. On physical exam, the infant is large for gestational age. He has good air movement through the lungs bilaterally, without retractions or nasal flaring. He appears well perfused with normal cardiac exam. He is not in a flexed posture and has a weak suck reflex. Screening tests reveal blood glucose of 44 mg/dL. What is the most likely diagnosis?	Hypoglycemia Hypoglycemia is a common presentation in an infant born to a diabetic mother with poor glucose control during her pregnancy. The increase in maternal serum glucose stimulates fetal pancreatic beta cells to increase insulin production, and this hyperinsulinemic state leads to hypoglycemia when the placental glucose supply is discontinued after delivery. A glucometer reading of < 35 mg/dL without symptoms or < 45 mg/dL with symptoms would confirm the diagnosis. This infant has signs of hypotonia, with absence of flexed posture and weak suck, and a blood glucose reading of 44 mg/dL, making hypoglycemia the most likely diagnosis.
A male infant weighing 3200 grams is born to a G1P1 female at 39 weeks gestational age via planned C-section. Maternal PMH is unremarkable, and GBS status is unknown. Apgars are 7 and 8 at 1 and 5 minutes of life, respectively. The delivery is uncomplicated, and the infant initially appeared in good condition. However, one hour following delivery the infant develops increasing respiratory distress. RR is assessed as 90 bpm. All other vital signs are within normal limits. On exam, the infant is acyanotic with rapid respirations and robust capillary refill. Chest x-ray shows bilateral lung fields with the appearance of “a radio-opaque line of fluid in the horizontal fissure of the right lung. No air bronchograms are noted. What is the most likely etiology of the infant’s respiratory distress?	Transient tachypnea of the newborn (TTN) Transient tachypnea of the newborn (TTN) is the most likely underlying etiology. This condition is caused by residual fluid in the infant’s lungs following delivery, and usually resolves within several days. It is more common in babies delivered via C-section, as the normal mechanical force of labor that helps expel fluid from the lungs is lacking. Babies with TTN and other forms of respiratory distress are often unable to nurse and require feeding via NG tube until respiratory status stabilizes. Respiratory distress syndrome (RDS) is less likely than TTN in this case. RDS is more common in premature infants and infants born to diabetic mothers. On chest x-ray, RDS is characterized by a ground-glass appearance and air bronchograms. Neonatal sepsis is possible, especially given the mother’s unknown GBS status, but relatively unlikely compared to the other options, especially given the mode of delivery. Sepsis can certainly cause respiratory distress, and if suspected, should be promptly evaluated with screening labs and blood cultures. Neonatal sepsis is also more common with prolonged rupture of membranes (PROM) > 18 hours prior to delivery.
Adam is a newborn male who was just born to a G2P1 mother at 36.2 weeks' gestation via a vaginal delivery. The mother reports that she did not receive prenatal care because she did not have insurance. She says that she thinks her “water broke” about two days ago, but she did not have any contractions after that, so she decided not to come to the hospital. She did not start having contractions until 19 hours before she delivered. After delivery, Adam did not cry vigorously, was tachypneic, cyanotic, and febrile to 100.5 F. Amniotic fluid did not contain meconium. His chest x-ray is normal. Given Adam’s birth history, what is the most likely cause of his symptoms?	Sepsis secondary to prolonged rupture of membranes Prolonged rupture of membranes (PROM) is when the chorioamniotic membrane ruptures before the onset of labor. The main risks associated with PROM are preterm labor and delivery and neonatal sepsis. Adam’s mom said that her “water broke” two days ago, which indicates that she had PROM. Adam’s mother also did not receive prenatal care; therefore, she did not receive any of the prenatal screening tests that she should have, which increases the likelihood that she has an infection that could have potentially been transferred to Adam after the rupture of her membranes. Adam’s history of PROM along with his fever and respiratory distress make this answer choice the best choice.
A newborn baby boy is born at 30 5/7 weeks' gestation after induction of labor for the severe maternal preeclampsia. He is noted to have subcostal and intercostal retractions, grunting, nasal flaring, persistent cyanosis, and tachypnea 30 minutes after delivery. Apgars were 6 (–2 for color, –1 for breathing and –1 for tone) and 7 (–2 for color and –1 for breathing) at 1 and 5 minutes, respectively. Due to lack of prenatal care and the mother’s presentation with severe preeclampsia, betamethasone x 1 was given during induction, but she did not receive a second dose prior to delivery. A chest x-ray is obtained, which reveals diffuse ground-glass appearance and air bronchograms bilaterally. What is the most likely diagnosis?	Respiratory distress syndrome (RDS) The baby boy is preterm, and his mother received only one dose of betamethasone, which puts him at increased risk for developing infant RDS, which is caused by insufficient surfactant. His physical exam and chest x-ray findings are consistent with RDS. TTN is a disorder of delayed reabsorption of fluid in the newborn’s lungs. Prematurity, delivery by C-section, being large or small for gestational age, or having a diabetic mother are all risks. In order to be diagnosed with TTN, the baby would need to show improvement within several hours. Although this is on the differential for the newborn baby’s condition based on clinical presentation, a chest x-ray should have shown perihilar streaking and other evidence of interstitial fluid.
Jaundice: accum bili in what skin layer?	Epiderm
Jaundice: Occurs what % newborns?	0.6
How does bilirubin travel in blood?	Binds ALBUMIN
Bilirubin: Transported by albumin to what site?	LIVER
Bilirubin: Conjugated in liver by WHAT ENZYME?	UDPGT
UDPGT: fxn?	Conjugates bilirubin (transported from blood to liver) with glucoronide
Bilirubin: Conjugated to WHAT MOLECULE in liver?	glucoronide (via UDPGT)
Conjugated bilirubin is excreted into bile in WHAT FORM?	Stercobilirubin
Unconj (indirect) or Conj (direct): Physiologic jaundice	Unconj
Unconj (indirect) or Conj (direct): Breast milk jaundice	UNconj
Unconj (indirect) or Conj (direct): Breast feed jaundice	Unconj
Unconj (indirect) or Conj (direct): Direct Coombs jaundice	Unconj
Unconj (indirect) or Conj (direct): Jaundice 2/2 spherocytosis	Unconj
Unconj (indirect) or Conj (direct): PK deficiency	Unconj
Unconj (indirect) or Conj (direct): Jaundice due G6PD	Unconj
Unconj (indirect) or Conj (direct): Jaundice 2/2 cephalohematoma	Unconj
Unconj (indirect) or Conj (direct): Jaundice 2/2 bruising	Unconj
Unconj (indirect) or Conj (direct): Jaundice 2/2 swallowed blood	UNconj
Unconj (indirect) or Conj (direct): Crigler–Naijjar	Unconj (decreased bili clearance)
Unconj (indirect) or Conj (direct): Galactosemia	Unconj (decreased bili clearance)
Unconj (indirect) or Conj (direct): Hypothyroid	Unconj (decreased bili clearance)
Unconj (indirect) or Conj (direct): Jaundice 2/2 neonatal asphyxia	Conj (due liver ischemia)
Unconj (indirect) or Conj (direct): Jaundice 2/2 sepsis	Conj (liver isch)
Unconj (indirect) or Conj (direct): Jaundice 2/2 congenital metabolic toxins	Cong (liver isch)
Unconj (indirect) or Conj (direct): Jaundice 2/2 biliary atresia, intestinal malrotation	COng
Physiologic jaundice: –seen in what kind of infants? –occurs in T bili <___ –peaks what day? resolves what day?	Full-term, healthy infants T Bili <15 Peaks d3–4 ––> resolves d4–5
Physiologic jaundice: what 2 mxns?	Lack gut flora & increased activity beta–glucoronidase ––> convert bili to unconj and reabsorb
Leads to what dz: Neonate lacks gut flora & has increased beta–glucoronidase ––> converts bili to unconj form ––> reabsorbs	Physiologic jaundice (normal, benign)
How disting: Physiologic vs. breast milk jaundice?	Physio appears d0 ––> peaks at d3 –– resolves d4 Breast milk: appears d4, peaks days 10-14
Breast–milk jaundice: underlying mxn?	INHIBITORY SUBSTANCE in milk ––> increase enterohepatic circulation
Difference in hemolysis mech bw DAT+ vs DAT neg?	DAT + = Antibody positive --> ABO/Rh incompatibility DAT neg = Antibody neg --> RBC membrane defects (sphero), G6PD def, pyruvate kinase def
Do RBC membrane defects (sphero) & enzyme defects (PK, G6PD) cause un/conj jaundice?	UNCONJ
3 etios of hepatobiliary dysfxn that can cause conjugated jaundice	Ischemia induced by: asphyxia, sepsis, congen metabolic toxins
Biliary atresia in neonate: Absent INTRA or EXTRA hepatic bile ducts?	EITHER
Biliary atresia in neonate: Assoc with what 2 other conditions?	Congenital HD Intestinal malrotation
Biliary atresia in neonate: If no tx ––> what complication ––> how long until die?	Develop cirrhosis ––> die 2yo
Suspect what dz: Neonate w/2 weeks of progressive jaundice	Biliary atresia
What dz: Acholic stools, hepatomegaly, dark urine, increased alk phos	Biliary atresia (conj/direct jaundice)
Conj or Unconj jaundice: See dark urine, acholic stools	DIRECT/CONJ
Biliary atresia in neonate: assoc w/elevation of which LFT?	ALK PHOS
Biliary atresia of neonate: possible to see increase in INDIRECT BILIRUBIN?	NO –– ALWAYS SEE INCREASED DIRECT BILI
Affect risk of severe hyperbili in newborn?: –jaundice at d0–1	Earlier jaundice ––> higher risk of severe hyperbili
What GESTATIONAL AGE: highest risk of severe hyperbilirubinemia	35–38!!!
Jaundice: increased risk: Breast or formula	Breast
Jaundice: increased risk: M or F?	Male
Jaundice: increased risk: White or Asian?	Asian (esp East Asian)
Jaundice: increased risk: young or old mom	>25yo mom
Require further w/u? Neonatal jaundice + VOMIT	Yes
Require further w/u? Neonatal jaundice + fever	Yes
Require further w/u? Neonatal jaundice + ONSET AFTER D3	YES
Require further w/u? Neonatal jaundice + high–pitched cry	YES
Require further w/u? Neonatal jaundice + bili <15	NO – suspect physio
Jaundiced neonate: Does normal CBC rule out hemolytic dz?	NO –––– order retic to check for anemia
Breast milk: Contain growth factors?	Yes
#1 carbohydrate in breast milk	Lactose
See lactose intolerance in neonates?	Uncommon 0–1yo
Breast milk: Fats comprise what % calories? Most fat at beginning or end of feed?	50% Most fat at end (encourage baby to drain boob)
Breast milk: Contains what 2 proteins?	Whey Casein
Breast milk: More or less protein than cowmilk?	3x cow > breast
Do not give regular cow's milk until what age? What could develop?	>1yo Colitis --> microscopic bleeding --> anemia
Colostrum: produced which days? slowly or rapidly replaced by milk?	d0–5 Slowly replaced by milk
Which has more: colostrum or breastmilk: –minerals –protein –fats –carbs –IgA	Minerals: col Protein: COLOSTRUM Fat: milk Carb: milk IgA: milk
Breast–feeding: affect incidence of: –SIDS? –Allergies? –DM?	Breast ––> decrease incidence all
Should mother expect menses while breastfeeding?	NO – no ovulate
Breast–feed: increase or decrease risk breast cancer in mother? ovarian cancer? osteoporosis?	Decrease all (since suppresses estrogen)
Breastfeed: Is it common for infant to fall asleep before finish feed?	YES
Breastfeed: How many feeds per day? How frequently? How many minutes each breast?	8–12 feeds/day Every 2–3h 15mins/breast
Breast milk contains all vitamins EXCEPT _____	Vitamin K
Do breast–fed babies req suppl Vitamin D?	Only if <15 min sun /week
Fluoride: supplement at what age? Under what conditions?	Suppl all infants >6mos if <0.3ppm
Kernicterus: stain what structures?	Basal ganglia & cranial nerve nuclei
Kernicterus: do to high levels of conj or unconj bilirubin?	Unconjugated
Kernicterus: highest risk if 1st or subsequent episode of jaundice?	Highest risk if FIRST episode of jaundice
Bilirubin encephalopathy: see HYPO or HYPERtonia?	TRICK Hypotonia early ––> hypertonia late
What dz: yellow baby with hypotonia, loss of suck reflex, vomit ––> hypertonia, szs, ataxia	Bilirubin encephalopathy (Kernicterus)
Bilirubin encephalopathy: early OR late?: Hypotonia	Early
Bilirubin encephalopathy: early OR late?: Hypertonia	Late
Bilirubin encephalopathy: early OR late?: Opisthotonous	Late
Bilirubin encephalopathy: early OR late?: Szs	Late
Bilirubin encephalopathy: early OR late?: Deafness	Late
Bilirubin encephalopathy: increased risk in whites or Asians?	Asians
Bilirubin encephalopathy: Assoc w/prematurity?	Increased risk if premature
Bilirubin encephalopathy: Assoc w/altitude?	Increase risk at high alt
Bilirubin encephalopathy: What other medical problem is a risk factor?	Small bowel obstruction
How tx: Breast + jaundice + bili 16–25	Cont breast + observe OR Suppl formula 24–48h + phototx
How tx: Term + jaundice + hemolysis + bili 17.5–23	Exchange transfusion
Can you administer phototx while breast–feeding?	YES
Neonate w/hyperbili: can you lower via admin H2O/dextrose?	NO
Neonate: What day stop meconium ––> yellow BM	day 3
Neonate: what day: 3–4 stools/day	By d6-7
By d3–4 life: how many stools per day? how many wet diapers?	3–4 stools 3–4 wet diapers
By d6 life: how many stools per day? how many wet diapers?	3–4 stools 6 diapers
Return to birth weight at what age?	2w
At d5 life: –at what % of birthweight? –require w/u at what %?	At d5: 7–10% below birthweight If >10% or no regain bw by w2 ––> further w/u
Anterior fontanelle: –suspect what problem if barely open at birth? –what is avg diam?	Over–riding sutures (benign; separates w/in few days) Avg: 2.5 – 5.0 cm
Name for: Edema/serum over presenting part of scalp	Caput succedaneum
Caput succedaneum: where located?	PRESENTING part of scalp (=edema)
Caput succedaneum: Leads to hyperbili?	NO –– overlies periosteum
Anatomic difference b/w: Caput succedaneum & cephalohematoma	Caput: edema overlies periosteum ––> NOT increase bili Cephalo: SUBperiosteal hemorr (not extend suture line) ––> can cause hyperbili
Cephalohematoma: –where located in re: periosteum –cross suture lines?	SUBperiosteal NOT cross suture lines
Can you approximate the bilirubin level based on the extent of jaundice?	YES
Estimated bilirubin level when jaundice at face? Below knees?	At face = 4-5mg/dL Below knees = 10-15mg/dL
Normal amount of breast tissue (mm) in term infant. What does unilateral or bilateral engorgement mean?	0.5-1.0cm Engorgement can happen for both male and females. If not warm/red, not mastitis
Suspect what problem: Neonate 0–72h & anorexia/vomit/sz	Inborn error of metab
What fraction of sick, full–term neonates without infection risks have an underlying metabolic dz?	20% !!! (1/5) ––– that's a lot
Inborn error of metabolism: can appear insidiously?	Yes
Neonate screen: all states screen what 2 dzs? What method?	PKU Hypothyroid via tandem mass spec
Red reflux: see from how far away?	1 foot
Spleen: normally how far below L costal? Should you push to find tip?	1–2 CENTIMETER below L costal Never push to find tip
Ortolani & Barlow: 1st perform at what age?	BIRTH
Developmental Dysplasia of Hip: More common L or R?	3x L > R
Developmental Dysplasia of Hip: F or M? White or black?	F White
Developmental Dysplasia of Hip: Assoc w/birth position?	More common BREECH
Developmental Dysplasia of Hip: Genetic component?	Higher risk if FHx DDH
Neonate phys exam: Perform hip exam at what ages? (to assess DDH)	0–3mos
What test: Thumb on lesser trochanter ––> flex hip ––> downward pressure	Barlow Test
Barlow test: –where is thumb? –flex or extend hip? what degree? –ab/duct?	Thumb on LESSER trochanter ––> flex to 90 ––> ADDuct & down
What test: Abduct hip & push femoral head anteriorly	Ortolani
Ortolani maneuver: –ab/duct hip? –push fem head ant or post?	ABDUCT (contrast Barlow – adduct) Push fem head ANTERIORLY over greater troch
Barlow or Ortolani: Feel CLUNK	Ortolani
A 4-day-old baby boy presents for his first pediatric well child visit. His birth history consists of an uncomplicated normal spontaneous vaginal delivery after 7 hours of labor—no vacuum or forceps assistance were used. The patient is the first child to a 30-year-old mother of Mediterranean descent. Mom is very concerned that her baby has started to look “yellow” since leaving the hospital. She has been breastfeeding every 2–3 hours and says that the baby latches on for 1–5 minutes for each feed. He has had few wet diapers, and mom is concerned he is not getting enough to eat. Which of the following would most aid in narrowing the differential diagnoses?	Fractionated bilirubin The test that will give you the most information at this juncture is a fractionated bilirubin. With the knowledge of the total serum bilirubin (TSB) and direct serum bilirubin, one will be able not only to narrow the differential (hemolysis vs. obstruction), but also to guide treatment (i.e., indirect serum bilirubin may be above phototherapy level). TSB can also indicate if the situation requires more drastic measures, such as a transfusion exchange.
A concerned mother brings her 7-day-old son to your office after noticing yellowing of his skin for 2 days. She has also noticed he has not been gaining weight since she brought him home from the hospital 5 days ago. This is her first son and she has been trying to do everything perfectly, including breastfeeding him, since she was told that breast milk provides adequate nutrients and other healthy benefits, like antibodies and growth factors. However, upon further questioning, she is feeding him only 6 times a day for 10 minutes each time. She admits her breasts often feel full and are not relieved by nursing. He was born full term by spontaneous vaginal delivery but had a hard time sucking with breastfeeding. Upon exam, he looks dehydrated and appears to have jaundice of the face and chest. He has also lost > 10% of his birth weight. What could be the cause of his jaundice?	Breastfeeding Jaundice Breastfeeding jaundice is the correct answer because it usually appears early in the first week of life and is caused by various factors, including poor breast milk intake. A decreased milk supply leads to limited enteral intake and can lead to increased enterohepatic circulation. Increased enterohepatic circulation describes the process where unconjugated bilirubin is reabsorbed in to the bloodstream where it binds to albumin and is recirculated.
A 5-day-old infant presents with a chief complaint of jaundice. As you obtain a careful history and physical examination, which of the following would NOT be a risk factor for jaundice in this infant?	PKU Phenylketonuria (PKU) is an autosomal recessive metabolic disorder due to a mutation in phenylalanine hydroxylase, which is required to convert phenylalanine to tyrosine. PKU leads to buildup of phenylalanine in the brain, leading to mental retardation, seizures, and death if not detected and treated early. It is not associated with jaundice.
A 3-week-old baby boy is brought to his pediatrician with a chief complaint of light tan–colored stools and worsening jaundice. His is exclusively breastfed and has 6–8 wet diapers per day. On exam, he appears to have scleral icterus and jaundice. Upon further workup, he is found to have an elevated direct bilirubin. What is his most likely diagnosis?	Biliary Atresia Biliary atresia can present anytime between birth and 8 weeks of age, but usually occurs after 2 weeks of age. Jaundice is usually the first presenting finding, along with acholic stools, dark urine (from increased bilirubin excretion) and hepatosplenomegaly if the problem goes unrecognized. Laboratory values classically show an increased level of direct or conjugated bilirubin > 2 mg/dL. If biliary atresia is confirmed with further laboratory testing and imaging, surgical intervention must be pursued as soon as possible.
Congenital hypothyroidism: how affect ammonia level?	No change (normal NH4)
Newborn metabolic screen: uses what lab technique?	Mass spec
Screens for what dz: Measure immunoreactive trypsinogen	Cystic fibrosis
How define: Lethargy	1. Decreased eye movements OR 2. fail to recog parents or interact w/environ
Name for: Decreased eye movements & fail to interact w/parents or environ	LETHARGY
How define: FTT	Fail to regain bw by 3 WEEKS or continuous wt loss after 10d life
What is difference and which most common: 1' vs. 2' vs. 3' hypothyroidism	1': thyroid dysfxn (95%) 2: pit 3: hypothal
Congenital hypothyroidism: most common what ethnicities? (2)	Native Am Hisp
Mxns of congenital 1' hypothyroidism	Thyroid ectopy A/hypoplasia Errors of thyroid hormogenesis
1' hypothyroidism: low or high TSH?	HIGH (HPA intact; prob is thyroid)
1' or 2/3' hypothyroidism: Low TSH	2/3 (pit/hypothal not producing TSH ––> low T4)
Does maternal thyroid hormone cross placenta?	YES Infant with congenital hypothyroid appears normal at birth due maternal thyroid
Congenital hypothyroidism: when do s/sx present?	6 WEEKS OF AGE appears late bc of placental transmission of maternal thyroid hormone
Congenital hypothyroidism: Constip or diarrhea?	Constip
Congenital hypothyroidism: How does skin appear?	JAUNDICED, mottling
Congenital hypothyroidism: Small or large fontanelles	LARGE
Congenital hypothyroidism: Hypo or hypertonia	HYPO
Congenital hypothyroidism: Hypo or hyperthermia	Hypo
Congenital hypothyroidism: What abdominal defect?	Umbilical hernia
Infant hypo or hyperthyroidism: See umbilical hernia	Hypo
What dz: Normal neonate ––> 6w age p/w feeding probs, jaundice, large fontanelle, hypotonia ––> large tongue, puffy myxedematous face & M.R.	congenital hypothyroid
What is next step: Newborn screen shows low T4, high TSH ––> ?	START L–THYROXINE then resend blood to confirm (do NOT wait to start tx)
Congenital hypothyroid: initiate L–thyroxine ––> what is goal TSH? T4?	TSH: 1 mU/ml T4: upper 1/2 normal
Congen hypothyroid: measure T4/TSH how often?	2w ––> 4w ––> q1–2 mos until 1yo ––> q2–3mos until 3yo ––> q3–12 mos until complete growth
How obtain FONTANELLE SIZE?	Avg length & width
Large fontanelles assoc with…?	Skeletal disorders (e.g. rickets, osteogenesis imperfecta) Chromosomal abnormalities (e.g., Down syndrome) Other conditions (e.g., hypothyroidism, malnutrition, increased intracranial pressure, shaken baby syndrome)
Premature closure / Small Fontanelle assoc with…?	Microcephaly Craniosynostosis Hyperthyroidism Normal variant
Sunken fontanelle assoc with…?	Dehydration
Bulging fontanelle assoc with…	Increased intracranial Pressure: -meningitis -hydrocephalus -subdural hematoma -lead poisoning
A two-month-old female presents to clinic for a well-baby checkup. Mom has been happy because the “baby rarely cries and sleeps all the time.” On exam, the baby has yellowing of the skin, decreased activity, appears to have decreased tone, and a large anterior fontanel. What is the most likely diagnosis?	congenital hypothyroid Congenital hypothyroidism may not be clinically evident until 6 weeks of age due to circulating maternal thyroid hormone transmitted from the placenta. Signs and symptoms of congenital hypothyroidism include feeding problems, large fontanels, hypotonia, large tongue, coarse cry, and frequently an umbilical hernia. Congenital hypothyroidism should be picked up on routine neonatal screening.
Jade is a 2-week-old female who was born at home and received no newborn screenings for congenital disease. Her mother brought her to the pediatrician's office concerned that her daughter appeared to be jaundiced and was constipated, tired, and not feeding well most of the time. Physical exam was notable for enlarged fontanels, jaundice without bruising, hypotonia without tremor or clonus, and an umbilical hernia. There was no sign of virilization, no abnormal facies, and no history of vomiting. Review of systems was otherwise negative except as stated above. Which of the following is the most important next step in Jade's management?	Consult with pediatric endocrinologist and start treatment with 10 to 15 mcg/kg/day of crushed levothyroxine in liquid, and follow up every 12 months This choice is correct because the American Academy of Pediatrics recommends this treatment regimen for infants age 0 to 6 months old. Dosing is based upon age and weight. It would also be important to consult with a pediatric endocrinologist to evaluate the short and long-term treatment plan. In addition, the specialist could also recommend screening for other autoimmune disorders.
A 6-week-old infant girl whose family recently immigrated from Mexico is brought to clinic for “excessive sleepiness.” The mother states the infant is not easily aroused for feedings and is not as active as she was previously. She is also concerned about her daughter's large “outtie belly button. On exam, the patient is afebrile and jaundiced, with a puffy myxedematous face. The fontanels are large but flat. There is a large umbilical hernia. When asked about the results of a newborn screening exam, mom states that the screening was never performed. What would be an expected abnormal lab value(s) associated with her condition?	High TSH, low T4 Congenital hypothyroidism may present with poor feeding, constipation, jaundice (longer and more persistent than physiologic jaundice of newborn), mottled skin, large fontanels, hypotonia, hypothermia and an umbilical hernia. Later findings include a hoarse cry, macroglossia, and myxedematous facies. Patients usually remain asymptomatic until after 6 weeks of age, as maternal thyroid hormones may still be in younger infants. Patients with primary hypothyroidism will have high TSH and low T4 levels. The most common cause of primary hypothyroidism will be aplasia or hypoplasia of the thyroid gland, and—much less commonly—inborn errors of metabolism. Secondary or tertiary hypothyroidism (HPA dysfunction) will have both low TSH and low T4, and are relatively rare causes of hypothyroidism in infants
A 45-day-old infant is brought in by his mother due to lethargy, constipation, and yellow skin color noted since birth. The mother and the baby moved to the U.S. from a foreign country that does not screen its newborns. The baby has been fed only formula since birth. Physical exam of the neonate reveals additional findings of large fontanelles, umbilical hernia, a large tongue, and abdominal distension. What is the next best step in diagnosis?	TSH This choice is correct because the constellation of baby’s problems is best accounted for by untreated congenital hypothyroidism. Unfortunately, severe mental retardation is unavoidable at this point because this condition should have been treated since birth. In the U.S., it would have been detected on the newborn screen.
The parents of 5-month-old Tiffany are concerned about Tiffany’s decreasing oral intake over the past 4 days. They report that she has been sleeping more but seems to tire out when feeding; in fact, mom’s breasts have become quite engorged and she needs to pump to relieve the pressure. In addition to the sleepiness and poor feeding they report that she has not had a bowel movement in 3 days. She has no fever or respiratory symptoms. You note a weak cry on your exam, and a floppy baby when you try to sit her up. What additional finding are you likely to find on your exam?	Absent deep tendon reflexes This infant likely has infant botulism which usually presents in the first year of life with hypotonia, lethargy, constipation, weak cry and can eventually lead to respiratory failure. These infants will have absent DTRs.
You are called down to the nursery to evaluate a newborn girl who is ready to be discharged. The mom is concerned because this 3-day-old has become lethargic and doesn’t want to feed. She has vomited twice and is showing no interest in feeding. On physical exam you note a lethargic infant with an enlarged liver and worry about an inborn error of metabolism. Which test would be diagnostic for an ornithine transcarbamylase (OTC) deficiency?	Hyperammonemia and elevated urine orotic acid Both hyperammonemia and elevated urine orotic acid are diagnostic of OTC deficiency, an x-linked condition, the most common urea cycle disorder.
Infant UTI: how obtain urine sample?	CATH (NOT bag specimen)
Fever: #	100.5 (38)
Name for: Viable bacteria in circulation	Bacteremia (not necessarily systemic dz)
Name for: Systemic dz 2/2 microorgs in circ	Septicemia
Difference b/w: Fever w/out source AND fever unknown origin	Fever W/out source: no focus despite H&P Fever of Unknown origin: 2weeks 101F fever with 1w failed w/u
Fever of unknown origin: present for how long?	2w (with 1w of failed w/u)
Occult bacteremia: definition (what tests)	Pos blood cx despite normal: 1. CXR 2. UA 3. LP
Occult bacteremia: see in what age range?	0–3yo
Qualify as SERIOUS bacterial illness (SBI)?: Enteritis	Yes
Qualify as SERIOUS bacterial illness (SBI)?: PNA	Yes
Qualify as SERIOUS bacterial illness (SBI)?: Cellulitis	Yes
Qualify as SERIOUS bacterial illness (SBI)?: Osteomyelitis	Yes
Qualify as SERIOUS bacterial illness (SBI)?: Otitis Media	No
Meningismus: due to stretching of nerves in what SPACE?	Subarachnoid
Nuchal rigidity: in/vol?	INVOL
Name for: Extreme nuchal rigidity ––> hyperextend entire spine	Opisthotonus
What is it?: Opisthotonus	Extreme nuchal rigidity ––> hyperextend entire spine
Name for: flex hip & extend knee ––> pt resists knee extens	Kernig
Name for: flex neck ––> pt flexes knee & hip	Brudzinski
Difference b/w: Kernig Brudzinski	Kernig: flex hip ––> resist knee EXTENSION Brud: flex neck ––> automatic flex knee & hip
If you plan to tx infant w/IV abx for presumed bacterial infxn ––> do you require a LP?	YES – RULE If want to use IV abx ––> get LP first
LP contraindication: platelets <___ (#)	<50k
Must perform LP if fever <__ (what age)?	1yo
Does normal CSF definitively r/o meningitis?	YES
Febrile infant: Suspect UTI in what ages?	2mo – 2yo
Gastroenteritis: see low or high fever with: –viral –bact	HIGH FEVER with both
Upper resp infxn: see low or high fever?	Can see high fever
Work–up of BACTERIAL infxn: low or high predictive value: >15,000 WBC w/left	LOW PREDICTIVE VALUE
Viral infection: do most have ab/normal WBC?	Most have NORMAL
UA: nitrites have high or low: –spec –sens	HIGH SPEC (few FPs) LOW SENS (many FNs)
UA: is a positive LE enough to dx UTI?	No – only indicates that WBCs are in urine
Voiding cysturethrogram (VCUG): order in which infants?	ALL infants w/SECOND uti
Vesicoureteral Reflux (VUR): is most mild/mod/severe? req tx?	Most mild ––> spont resolve
UTI in <1yo: what % have vesicourethral reflux?	0.5
VUR: affect risk of UTI? req ppx abx?	Increase risk of UTI ––> GIVE PPX ABX (until VUR resolves or surg)
VUR: what is alt way to monitor (if not want VCUG)?	Periodic radionuclide cystograms
UTI in infant: –duration? –route? –repeat urine cx?	7–14d po ––> IV if severe dehydr Repeat urine cx if no response after 2d
Pyelo: 2 most common pathogens	E coli > enterococcus
Pyelo: –2 best abx & route for INPATIENT –outpatient	Gent + Amp INTRAVENOUS , Ceftriaxone ––> TMP–SMZ bid (total 7–14d), alt=Cephalexin
Pyelo: what is disadvantage of: –Ceftriaxone –Ciprofloxacin	Ceftriax: no cover enterococci (#2), pseudomonas Cipro: damages articular cartilage (esp knees)
Nitrofurantoin: use in what type of UTI?	Lower UTI (cystitis) NOT pyelo
Sulfisoxazole: used to tx pyelo?	No – resistance
A 6-month-old infant arrives in the ED with a 12-hour history of poor feeding, emesis, and irritability. On exam, she is ill-appearing with T 39.2 C, P 160 bpm, R 40 bpm, BP 80/50 mmHg. CBC shows WBC 11.2, Hgb 13.5, Plt 250. Urinalysis shows > 100 WBC per hpf, positive leukocyte esterase, and positive nitrites. She has no history of prior urinary tract infection. Chest x-ray is negative. Urine and blood cultures are pending. After bringing her fever down, she was still uninterested in drinking, but her exam improved, and you were confident she did not have meningitis, so an LP was not performed. Which of the following is the best next step in management?	Intravenous ceftriaxone (nothing oral, not even amp+gent) This patient’s presentation is suggestive of a UTI. Given the ill appearance, vital signs, and white count, Upper tract disease (pyelonephritis) should be strongly considered. A parenteral (IV/IM) third-generation cephalosporin is the best choice of those listed for pyelonephritis, given its excellent gram negative coverage (except for Pseudomonas).
A 3-month-old male presents to the ED with a fever that started the previous day. Mother reports that he was fussy and had decreased oral intake. He had had five fewer diaper changes than usual. He had no vomiting, diarrhea, or respiratory difficulty. On physical exam his temperature is 101.6 F, pulse 110 bpm, RR 24 bpm, and BP 95/67 mmHg. The baby seems irritable and is not consolable by the parent. HEENT exam was significant for dry mucous membranes. Other than his irritability, the rest of the physical exam was unremarkable. CBC showed WBC 3.5, but was otherwise normal. BMP was within normal limits. Urinalysis showed positive leukocyte esterase, positive nitrite, and WBCs > 10/hpf. An LP was performed, and urine and CSF culture results are pending. The patient is placed on IV fluids and is started on cefotaxime. What is the next best step in evaluation?	Renal Bladder U/S This infant has a fever without other respiratory symptoms. Meningitis and UTI must be considered in patients with fever. The only way to rule out meningitis is by lumbar puncture. This patient has a low WBC, suspicious for sepsis, and a UA that is highly suggestive of UTI. Empiric therapy should be started to cover common organisms including E.coli, P. mirabilis, and Klebsiella. Cefotaxime is reasonable empiric therapy. Renal ultrasound is recommended for all infants with pyelonephritis to assess for renal structural abnormalities or signs of obstructive uropathy (hydronephrosis).
A 10-day-old boy is brought to the ED by his mother because of “fever.” Mom describes that the baby has been “sleepy” and feeding less vigorously than in the previous two days. She believes his urine output has also decreased. His birth history is notable for prolonged membrane rupture (about 32 hours), and maternal fever at the time of delivery. Prenatal and neonatal ultrasound revealed bilateral hydronephrosis. On exam, the infant is sleepy with a temperature of 38.5 C. A blood sample is sent for CBC, BMP, and culture. Attempts are made to obtain CSF and urine for analysis and culture, but only very small volumes of these fluids are obtained. Volume resuscitation is begun. Chest x-ray is performed with indeterminate results. What is the most appropriate next step?	Send samples for culture and begin parenteral antiobiotic treatment Given the presentation of fever in a neonate who presents with sleepiness and poor feeding, samples should be sent for culture and the baby started on empiric antimicrobial therapy. This infant is likely to have a urinary tract infection, and urosepsis is certainly a possibility, especially given his known urinary tract anoamlies. We have no way of ruling out meningitis from this presentation, so antibiotics should be initiated at meningitic dosing. In an infant younger than one month, fever with any suspicion of sepsis, whatever the source, requires immediate evaluation and initiation of antibiotic treatment. Because infants at this age have immature immune systems, they do not localize infections as well as older children. An infection of the urinary tract may lead to bacteremia, which in turn may lead to CNS infection. Only cultures will give us the information required to determine the appropriate type length of antimicrobial therapy.
A 6-month-old female is brought into the pediatrician’s office for three days of high fever, fussiness, and decreased appetite. The patient has not had any upper respiratory tract symptoms, vomiting, diarrhea, or rash. On physical exam the patient is fussy, has a RR of 28 bpm and a pulse of 160 bpm. She is febrile to 102.8 F (rectal). The patient is alert and fully moving all extremities. Apart from her vital signs, no other significant exam findings are noted. A CBC demonstrates leukocytosis of 17.0 cells x 103 / µL with elevated bands. What diagnosis is most likely?	UTI UTI, the most common bacterial illness in a female infant, is consistent with her high fever, fussiness, and decreased appetite. Her CBC suggests that she has a bacterial infection (leukocytosis and elevated bands). A sample of her urine should be obtained by catheterization and sent for urinalysis and culture.
A 6-month-old female with normal birth and developmental history presents with fever for the past two days, fussiness, and decreased appetite. ROS is negative. No abnormalities are noted on the physical examination. A urinalysis from a bag specimen is positive for leukocytes and nitrite, which suggests the presence of a UTI; a culture from this sample is pending. The patient is ill-appearing, dehydrated, and unable to retain oral intake. She is hospitalized, receives a 20 cc/kg NS bolus and is placed on maintenance IV fluids with clinical improvement. What is the best next step for management of this patient?	Urinary catheterization It is the best method for obtaining a specimen for culture that has not been contaminated by perineal bacteria, and for this ill child, you must determine the cause of the fever with accuracy.
Rapid Strep test… what is its specificity/sensitivity?	High specific --> If test is pos, don't need further confirmation Variable sensitivity --> Negative result needs to be confirmed by standard throat culture
Treatment for Strep Throat: -#days from start? Why? -Drug of choice? -Which one is more widely use? -If child refuses oral form of med?	within 9 days --> prevent acute rheumatic fever Oral PCN is drug of choice Oral Amoxicillin used more bc tastes better If oral refused --> single IM PCN
Always consider what dz: HIGH fever x 5d....	Kawasaki
Kawasaki: usually <___yo	<4yo
3 dzs with palmar rash	Kawasaki Syphilis RMSF
Kawasaki: requires how many findings?	4 (in addition to fever)
Kawasaki: where see rash (2)?	Groin PALMS
Kawasaki: what 2 eye findings?	1. Conjuncitivitis w/out discharge 2. ANTERIOR uveitis (slit lamp)
Anterior uveitis 2/2 Kawasaki: –how detect (what test)? –minority or majority of pts?	Slit–lamp 80% pts in 1st week
Strawberry tongue: what 3 dz?	1. Kawasaki 2. Strep pharyngitis 3. Infectious mono
Kawasaki: see lymphadenopathy?	YES
What dz: HIGH FEVER x5d, groin rash, conjuncitivitis, strawberry tongue, puffy/peeling hands & feet	Kawasaki
Kawasaki: low or high fever?	HIGH x 5d
4 causes of UNILATERAL cervical adenitis (non–cancerous)	1. Kawasaki 2. Cat Scratch 3. Pharyngeal infection ––> reactive node 4. Mycobacteria
Kawasaki: see uni/bilat lymphadenopathy?	UNILAT
SJS: –see conjuncitivitis? –what type of rash (name)?	Conjunctivitis Erythema multiform
#1 fatal tick dz	RMSF
RMSF: how transmit?	Tick
RMSF: what type of rash? where located?	Petichial rash on palms
What dz: Petechial rash, HEADACHE, fever, myalgia	RMSF
Kawasaki: see change in CBC?	1. INCREASE WBC, esp PMNs 2. Normocytic, normochromic anemia 3. Increase platelets (week 2)
Kawasaki: would you still suspect if negative ESR?	no persistence of an elevated ESR after the fever has subsided can help to distinguish Kawasaki disease from other infectious rash/fever illnesses
Kawasaki: see changes in LFTs?	INCREASE (nonspecific) decrease albumin
Suspect what dz: Increased WBC (esp PMNs), normo normo anemia, increased platelets, increased LFTs, STERILE PYURIA	Kawasaki
Kawasaki: what UA change? how collect UA?	STERILE PYURIA (2/2 sterile urethritis) Collect via CLEAN CATCH (would not detect pyuria by cath)
Kawasaki: order what imaging test?	Baseline ECHO ––> repeat ECHO 4 weeks
Kawasaki: how tx? (2)	HIGH–dose ASA (other antipyretics not effective) x6-8wks, then low dose ASA indefinitely HIGH–dose intravenous Ig (only tx ot decrease coronary art sequel)
Kawasaki: see CNS complications in what % pts?	90%: lethargy, aseptic meningitis
Kawasaki: see coronary art aneurysm in what % untx pts?	0.25
Kawasaki: what GI complication? (2)	Liver dysfxn (40%) Gallbladder hydrops (10%)
Kawasaki: after discharge ––> when return for repeat ECHO?	Echo at weeks 0 & 4 (usually return 2 weeks after discharge for repeat)
What pathogen: Vesicular rash on hands & feet; ulcers in mouth	COXSACKIE (enterovirus) ––> hand–foot–mouth dz
What pathogen: Hand–foot–mouth dz	Coxsackie (enterovirus)
What pathogen: Prodrome fever >101 ––> cough, runny nose, conjunctivitis ––> maculopap rash behind ears ––> reaches feet	MEASLES 3Cs
Measles: describe rash lesions & distrib	Maculopap Starts behinds ears ––> reaches feet w/in 2 days
Meningococcal rash: itchy?	YES
What pathogen: High fever 3d ––> fever ends ––> rash on trunk ––> spreads arms, neck	Rubeola
Rubeola: which see first: Rash or fever	Fever ––> fever ends ––> trunk rash
Rubeola: describe rash lesions & distrib	Maculopap on trunk ––> spreads arms/neck	Fever ends before rash appears
Rubeola: usu <__yo	<2yo
Strep pharyngitis (GAS): 2 systemic comps	1. Scarlet fever (blanching sandpaper) 2. Rheum heart disease
What pathogen: Blanching sandpaper rash & high fever	Strep pharyngitis ––> Scarlet fever
Scarlet fever: low or high fever?	HIgh
Scarlet fever: describe rash	blanching sandpaper starts groin/ax/neck ––> spreads
Scarlet fever: rash resolves how long?	<10d
Rheumatic fever: develops how long after strep infection?	18 days
What disease?: Jones Criteria	Rheumatic fever
Rheumatic fever: was diagnostic criteria (eponym)? req how many (#) criteria?	Jones criteria 1 major + 2 minor 2 major + 1 mintor
What dz: Migratory polyarthritis, peri/myocarditis, erythema marginatum, subQ nodules & chorea	Rheumatic fever (2/2 strep pharyngitis)
Rheumatic Fever: –what type of arthritis? –name for classic rash –what neuro disorder	MIGRATORY polyarth Erythema marginatum Sydenham's chorea
Rheumatic Fever: what EKG finding?	Prolonged PR
What viral exanthem: EKG – prolonged PR	Rheumatic Fever
What dz: Complication: peritonsilar abscess	Strep pharyngitis
VZV: starts where on body?	Trunk
VZV: resolves after how long?	1 week
A 5-year-old female, previously healthy, presents with an erythematous, vesicular rash on the palms and soles and a high fever for several days. Upon examination, she is also found to have ulcers in her mouth. A few days later, the fever and rash resolve. What is the most likely pathogen?	Enterovirus This presentation is consistent with infection by cocksackie A, an enterovirus. Following an incubation period of three to five days, patients have fever, tender vesicles on their hands and feet, and oral ulcers. Sometimes the rash also occurs on the buttocks and the genitals. The infection resolves spontaneously within three days, and is spread from person to person via saliva, fluid from the vesicles, stool, or nasal discharge.
A 2-year-old girl presents to the urgent care clinic with a 7-day history of high fever to 38.5 C, a maculopapular rash that began on the palms and soles of her feet, red eyes without discharge, and unilateral cervical adenopathy. What other symptom/sign might you discover on further history and exam?	Erythematous and edematous feet The constellation of symptoms described suggests Kawasaki disease. The other two classic signs not mentioned are erythematous tongue (“strawberry tongue”), and erythema/edema of the extremities, which is the best answer here.
A 3-year-old male presents with fever to 103 F for the past week, injected eyes, and a refusal to walk for the past two days. On physical exam, you note conjunctival injection without pus or exudates bilaterally, prominent papillae of his tongue with redness as well as redness of his hands, and feet. He also has a new non-diffuse maculopapular rash on his torso that gets worse with fever. On examination of the swollen extremities, you are unable to elicit any tenderness or effusions in any joints. Which of the following is the most likely diagnosis?	Kawasaki Disease Kawasaki disease (KD) is one of the most common vasculitides of childhood. For diagnosis, in addition to fever of > 5 days, patient must meet four of the following criteria: rash, conjunctivitis, unilateral cervical lymphadenopathy, changes in oral mucosa, or extremity changes (redness/swelling). Our patient does not have lymphadenopathy, but often this is the least common finding in KD. If children have fever with fewer than four of the five clinical findings, they can have incomplete KD if they meet certain laboratory criteria.
A 5-year-old male comes to the clinic with a chief complaint of four days of progressively worsening fever and that has been minimally responsive to acetaminophen. The patient complains of sore throat and decreased appetite. His sister had a positive rapid strep test and is now being treated with amoxicillin. Your concern is for Group A strep. What is the next best step in management?	Rapid strep test with back-up culture if negative Choice D would provide confirmation of your clinical suspicion and allow for correct diagnosis prior to empiric antibiotic treatment.
A 3-year old girl comes to the clinic with a chief complaint of fever (104F) for over a week. Her mom reports that she has been fussy and inconsolable since she became febrile. She has a red tongue, with large papillae, conjunctivitis, a palmar rash, unilateral cervical adenopathy, as well as swollen feet. Given the most likely diagnosis, what is the most important follow-up for this patient over the next few weeks?	Echocardiogram to look for coronary artery aneurysm children with Kawasaki disease are at high risk for coronary artery aneurysm formation and should receive an echocardiogram within four weeks of the onset of their illness. Use of IVIG for the treatment of Kawasaki disease has decreased the risk of coronary artery aneurysms significantly. Kawasaki disease is diagnosed when there is a fever plus four of the following: changes in oral mucosa (e.g., strawberry tongue), extremity swelling or redness, unilateral cervical adenopathy, conjunctivitis, and rash. Infectious and rheumatologic causes must be excluded in order to make the diagnosis of Kawasaki disease.
Asthma vs Reactive Airway Disease	RAD = Asthma in children under 3yo
What is most ominous finding of respiratory distress?	PARADOXICAL BREATHING
Paradoxical breathing: see what? indicates what condition?	Inspire ––> chest draws inward and abdomen rises due to downward displacement of abd content See in resp distress due to resp mm fatigue
Name for sound: Forced expiration against a closed glottis	Grunting
Grunting: due to what action?	Forced EXPIRATION against closed glottis
Grunting: see in what 3 lung dzs?	1. Atelectasis 2. PNA 3. Pulm edema
Head–bobbing in resp distress: synchronized with INSP or EXP?	INSP
Name for resp sound: musical, CONSTANT PITCH, loudest at neck	STRIDOR
Stridor: –constant or variable pitch? –where ausc loudest? –lower or upper aw?	Constant pitch (musical) Loudest at neck Upper aw
Stridor: see with insp, exp or both?	INSP ONLY (according to CLIPP)
Difference between: Wheeze vs. rhonchi	Basically same mxn Wheeze: high pitch Rhonci: low
Wheeze/rhonchi: –due to RESONANCE? –see w/insp, exp or both? –where loudest?	NOT due resonance; due to VIBRATION of narrowed aws EXP (or exp+insp; never insp alone) loudest at chest
What resp sound: Only hear during EXP or EXP+INSP (never insp alone)	Wheeze/rhonchi
Wheeze/rhonchi: does longer & higher pitch indicate more severe dz?	YES
Crackles: dis/continuous?	DISCON
Crackles: sound differences b/w coarse & fine	Coarse: low pitch, loud, few Fine: high pitch, quiet, many
Lower or upper aw obstrution: Wheeze	Lower
Lower or upper aw obstrution: Prolonged expiratory phase	Lower
Lower or upper aw obstrution: VIRAL URI	LOWER!!!! (see wet cough, no wheeze)
Viral URI: common to see wheeze?	NO
Asthma: is wheeze severity correlated with asthma severity?	NO If severe asthma with no air exchange ––> no wheeze (BEWARE)
Severe asthma ––> what CV change?	Pulsus paradox
What dz: CXR shows: Bilat hyperinflation, flat diaphs, atelectasis	Asthma
Lower or upper aw obstrution: Acute bronchiolitis	LOWER Edema/mucuus ––> obstruct bronchioles
Lower or upper aw obstrution: Pertussis	LOWER
Acute bronchiolitis: What % due RSV?	0.5
Acute bronchiolitis: In addition to RSV – what other viruses?	para/influ
Acute bronchiolitis: See what temps? (#)	38.5 – 39
Acute bronchiolitis: See wheezing?	YES (contrast VIRAL URI)
Acute bronchiolitis: How appear CXR?	Bilat hyperinflat (sim asthma) w/scattered atelect
Asthma: due inflamm/edema of mucosa or parenchyma?	Mucosa (contrast PNA – parenchyma)
Pneumonia: what BACTERIAL pathogen: –5–6yo (#1) –school age (#1–2)	5–6yo: Strep pneumo School: MYCOPLASMA #1, Strep pneumo #2
Viral pneumonia: what 4 viruses common?	RSV, para/influ, adeno
Indicates what dz: Crackles	PNA (bact or viral)
Chlamydia trachomatis PNA: presents how long after birth?	3–4w
Whooping cough: what pathogen?	Bordatella pertussis
Bordatella pertussis: vaccine is how effective? (%)	70–90%
What pathogen/dz: 3 stages (catarrhal, paroxysmal, convalescent)	Bordatella pertussis
Bordatella pertussis: 3 stages & duration of each	1. Catarrhal: 1–2w (URI sxs) 2. Paroxysmal: 4–6w (staccato) 3. Convalescent: mos cough
What dz: Staccato cough	Bordatella pertussis (whooping)
Bordatella pertussis: cough may persist how long?	Paroxysmal cough 4–6w ––> regular cough for mos
Lower or upper aw obstruct: Foreign body	Upper
Lower or upper aw obstruct: Epiglottitis	Upper
What dz: Asymmetric wheeze in 5yo w/out hx aw dz	foreign body
Foreign body asp: most common location	R mainstem bronchus
Decubitus CXR to determine which side foreign body is aspirated	If lying on right and right side stays hyperinflated --> right lung obstruction bc air is trapped and mediastinal contents cannot compress it down like it normally would
Treatment for foreign body aspiration?	Rigid bronchoscopy
Epiglottitis: what age group?	2–5yo
Lower or upper aw obstruct: Croup	TRICK – both (subglottic)
Croup: caused by 6 pathogens	Para/influ Adeno RSV MYCOPLASMA MEASLES!!!!
Indicates what dz (general name): Insp stridor + barking cough	Croup
A 12-year-old male presents to the ED with complaints of anorexia, weight loss, and persistent cough, with nocturnal coughing fits that have been waking him from sleep for the past three weeks. He denies fever, chills, myalgia, sore throat, or rhinorrhea. The patient presented to his primary care physician one week prior with the same complaint, and was treated with amoxicillin and bronchodilator therapy. His chest x-ray was negative for infiltrates at that visit. The patient's symptoms did not improve with this regimen. The cough became more frequent, sometimes causing emesis. Which of the following is the most likely diagnosis?	Infection with Bordetella pertussis in the paroxysmal stage The paroxysmal stage of pertussis lasts four to six weeks and is characterized by repetitive, forceful coughing episodes, followed by massive inspiratory effort. This massive inspiratory effort is what results in the characteristic whoop-sounding cough. This is consistent with the patient's presentation and duration of illness. The forceful coughing fits in pertussis can even lead to conjunctival hemorrhages and pneumothoraces from the increased intrathoracic and intracranial pressures from Valsalva. The antimicrobial agents of choice for treatment of pertussis are azithromycin, clarithromycin, and erythromycin. Antibiotics given in the paroxysmal phase will reduce communicability but will not alter the clinical course.
A 12-month-old previously healthy girl presents with cough and mild subcostal retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest x-ray demonstrates unilateral air trapping. What is the most likely diagnosis?	Foreign Body Aspiration Features of foreign body aspiration include unexplained wheezing and asymmetric breath sounds, as well as air trapping in one lung indicating unilateral airway obstruction. The right main bronchus is the more commonly obstructed due to anatomy (it is wider and more vertical than the left). The most commonly aspirated foods are hot dogs, nuts, hard candy, grapes, and popcorn.
A 10-month-old infant is brought to the Peds ED by her parents, who say she has been coughing persistently for the last three hours. The parents were watching a movie at home when they first noticed their daughter coughing. Patient is a vaccinated, well-nourished infant in moderate distress with retractions, nasal flaring, and grunting. On auscultation, you immediately notice diminished breath sounds in the right lung with normal breath sounds on the left. What other associated physical exam finding do you expect to hear?	Asymmetric breath sounds and wheezing This infant is in respiratory distress from foreign body aspiration, consistent with the history of acute onset of distress and asymmetric breath sounds. Common foreign bodies include peanuts, popcorn, grapes, hard candy and hot dogs. Respiratory distress from foreign body aspiration is usually accompanied by asymmetric breath sounds and wheezes on auscultation.
Susie is a 3-year-old girl brought into the clinic by her mother because she has a gradually worsening cough and she has been having trouble breathing. Her mother says Susie sounds like she is barking when she coughs. Susie is up to date with her vaccinations. Susie’s mom always watches her when she’s playing. On physical exam, you note that Susie has inspiratory stridor. She does not have wheezing, there are no retractions, and she has symmetrical breath sounds. No pseudomembranes are appreciated on physical exam. What is Susie’s most likely diagnosis?	Croup (laryngotracheobronchitis) Croup or laryngotracheobronchitis is due to a viral infection (Parainfluenza type 1). It is most common in the winter, and often occurs in children age 2 to 5 years. Croup can lead to non-specific URI symptoms with some degree of airway obstruction. A barky or seal-like cough and inspiratory stridor (which should be differentiated from expiratory wheezes) is common in croup.
Joe, a previously healthy 11-month-old male with 5-day history of a “cold,” is brought to the ED by mom for one day of acute worsening cough and intermittent wheezing. Per mom, the cough was initially dry but has become more “phlegmy,” making it difficult for Joe to breathe, particularly when he is feeding or more active. His immunizations are up to date, and he has no known allergies. His family history is significant for a 6-year old sister who was diagnosed with asthma four years ago. On exam, Joe is afebrile, mildly tachypneic with normal O2 saturation. He has prominent nasal flaring and mild subcostal retractions. He has clear rhinorrhea but no evidence of oropharyngeal erythema. Lung exam reveals decreased breath sounds and wheezes on the right. What is the most likely diagnosis?	Foreign body aspiration Given Joe’s age, foreign body aspiration should always be included in the differential diagnosis for acute onset wheezing. The lung findings of asymmetric breath sounds and wheezing support this diagnosis. Foreign body in the airway can be confirmed by bilateral decubitus or inspiratory/expiratory chest films, characterized by decreased deflation on the affected side. If complete obstruction, x-ray will generally reveal atelectasis (whiting out) and signs of volume loss (mediastinal shift towards affected side to compensate for loss of volume).
If atopic parent ––> what is risk to child? (%)	30% risk
Has rate of asthma increased in recent years?	2x increase in 15 years
#1 chronic dz in peds	asthma
Asthma: how long last & what cells involved: –early rxn –late rxn	Early (0–1h): masts & eosinos ––> increase perm/mucus & bronchocon Late (2–3h later): eosino, PMN, leuko ––> epi destruct & remodel SM
Asthma: –how many hrs until late rxn peaks? resolves? –how long does airway hyperresponsiveness persist after late rxn?	peaks 4–8h ––> resolves 24h aw hyperresponsive for days–wks
Asthma: wheeze in what part of resp?	End–expiratory
How do allergies ––> chronic cough?	Allergy ––> nasal congest ––> PND ––> noct cough
What dz: COBBLESTONE post pharynx	Allergies: PND ––> lymphoid hyperplasia
Allergic rhinitis: what TYPE of hypersens rxn?	Type 1 (immed)
Allergic rhinitis: how tx? (2)	Antihistamine topical nasal steroids
What is this: often preceded by URI, nocturnal cough, PND, bilateral purulent nasal secretions, malodorous breath	Sinusitis
Sinusitis: req sxs how long?	1week purulent nasal discharge
Sinusitis: see fever?	YES
Sinusitis: nose & throat swabs useful?	No
Sinusitis: 4 most common bact	S pneumo H flu M catar Strep PYOGENES
Sinusitis: tx with what class?	B–LACTAMS –cefuroxime –augmentin
What is this: presents like Sinusitis but UNILATERAL symptoms	nasal foreign body
When develop: –ethmoid sinuses –max sinuses –frontal	Ethmoid & max: at birth Frontal: 6–8yo
What is this: extension of viral inflammation into lower respiratory tree, prolonged congested cough with URI sxs	Bronchitis
Bronchitis: s/sx worse day or night?	EQUAL (no change w/temp,exercise)
Think what dz: Rhonchi	Bronchitis
Atypical/viral PNA: s/sx change w/temp, exercise?	MAY WORSEN (contrast Bronchitis)
Atypical/viral PNA: expect cough for how long?	8–12w
How does GERD ––> nasal congestion?	NASAL reflux ––> congest
Habitual cough: what is initial trigger?	Viral URI
What dz: Brassy, short, dry spasmodic cough; no change w/exercise, cold; resolves w/sleep	Habitual cough
Fungal pulm infxn: dry or wet?	DRY
Chlamydia PNA: intermittent or paroxysmal cough?	Parox! (violent attacks)
Mycoplasma PNA: intermittent or paroxysmal cough?	Parox! (violent attacks)
Suspect what dz: Chronic cough + palpitations	CHF
Suspect what dz: Chronic cough + abdominal pain	PNA
Insp:Exp ratio: –normal –restrictive lung dz –obstructive	I:E Norm: 1:2 Restrict: 1:1 (recoil air out fast) Obstruct: 1:3 (due to air–trapping = asthma, CF)
Due obstruction in small/med/large aw: Rhonchi	Large
Due obstruction in small/med/large aw: Wheeze	Mod
Due obstruction in small/med/large aw: Rales	Small (contrast rhonchi: large)
Difference between: Variable & fixed obstruction	Variable: insp OR exp only Fixed: BOTH insp & exp
If immunized child w/chronic cough ––> suspect pertussis?	Unlikely
Fungal PNA: –is cough productive? disturb sleep? –chest pain?	Non–productive cough, not disturb sleep PLEURITIC chest pain
What type of cancer can present with chronic cough?	Mediastinal lymphoma
Child with 1' TB: See what changes on CXR?	FEW/NO CHANGES (little evidence of initial focus) May see focal hyperinflat, atelect
Suspect what dz: *Large regional lymphadenitis + non–productive cough + FTT + fever/congestion	1' TB
Common sequence seen in pediatric TB?	1. Hilar adenopathy (most common xray finding) 2. Focal hyperinflation 3. Atelectasis
Pediatric Tb: see small or large regional lymphadenitis?	LARGE
Pediatric TB: which lobar segments at increased risk?	EQUAL RISK 2+ foci in 25% pts
Pediatric TB: see local effusions on CXR?	YES
If suspect TB and pt is symptomatic ––> how officially dx?	sputum cx OR 1st AM gastric asp (positive PPD also useful in ped)
What size: Positive PPD in LOW–risk / asymptomatic child	>15mm
Asthma: how tx: Mild intermittent	B–agonist
Asthma: how tx: Daily persistent asthma	B–agon + inhaled cortico
Inhaled corticosteroid: how long until see improvement?	few weeks
Asthma: if Leukotriene inhibitor corticosteroids ––> monitor what 4 things?	1. BP (HTN) 2. Blood glucose 3. Growth 4. Cataracts
Asthma: does administration of leuko–synth inhibitor affect the req dose of inh steroid?	allows lower dose steroid
Asthma: which more effective: Inh steroid or leuko–inh	STEROID
Asthma: can you use leuko–inh as monotherapy?	NO
If see CXR with mediastinal/hilar adenopathy ––> think what 3 dzs?	1. TB 2. Fungal PNA 3. malig
Obstructive or restrictive: Decrease FEV1/FVC	Obstruct
Asthma: decrease or normal FEV1/FVC	Decrease
Obstructive or restrictive: SLE	Restrictive
Obstructive or restrictive: Normal FEV1/FVC	Restrict
A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests?	Chest x-ray and tuberculin skin test Signs and symptoms of primary pulmonary tuberculosis are few to none. Toddlers may present with nonproductive cough, mild dyspnea, wheezing, and/or failure to thrive (defined as weight < 5th percentile or drop in two percentile curves for weight). In children, TB can present without systemic complaints (fever, night sweats, and anorexia), severe cough, and sputum production. Regarding diagnostic tests, the TST is a practical tool for diagnosing TB infections. All children with chronic cough (more than three weeks) should be evaluated with a chest x-ray, as other pathology—such as lung abscess or malignancy—can also be detected on CXR.
An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy?	Low dose inhaled corticosteroids Low dose inhaled corticosteroid is correct because this patient has mild persistent asthma. His symptoms occur 3–6 days/week and 3–4 nights/month.
A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would be characteristic of the cough that this patient would present with?	Worse at night Asthma frequently presents with nighttime exacerbations. The cough often presents with wheezing and is usually a dry cough.
A 9-year-old male presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. He has struggled with these complaints over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him?	Short-acting beta agonist PRN with low-dose inhaled corticosteroid Persistent cough and wheezing that affect the patient every other day (3-4 days with symptoms/week) are consistent with mild persistent asthma, which is appropriately treated with short-acting beta agonist PRN and low dose inhaled corticosteroid. The swelling under the eyes (allergic “shiners”) and skin rash are other signs of atopy, as mentioned above.
A 10-year-old male comes to the clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup?	Alevolar consolidation in the RLL Pneumonia is the most likely cause for his symptoms and a chest x-ray would be a great confirmation of your suspected diagnosis. Eliciting a complete history might reveal history of an upper respiratory infection. Localization of crackles (discontinuous inspiratory sounds) to one lobe makes pneumonia more likely.
Name for: Mid ear fluid + s/sx ear infxn (bulge, drainage)	ACUTE OM (contrast OME = NO s/sx of infxn)
How different: AOM vs. chronic OME (OM with effusion)	AOM: fluid + s/sx Chronic OME: fluid – s/sx
AOM: 4 most common bact pathogens	#1 Strep pneumo #2 H flu M cattarhalis Strep Pyogenes
AOM: 3 common VIRAL pathogens	Influ RSV Rhino
AOM: higher bottle or breast? Assoc w/pacifier? genetic component?	Bottle Increase risk if pacifier FHx
AOM: M or F?	M > F
AOM: assoc w/SES?	Increased in LOW SES
AOM: highest what ethnicity?	Native American
What dz: TMs retracted & amber & decreased mobility	Chronic OME
Ear exam to r/o AOM: which is more reliable: TM color OR position/mobility	Position/mobility
Ear exam: Is RED TM alone a good predictor of AOM?	NO
What test: Objective eval TM mobility	Tympanogram
What test: Audio thresholds via EARPHONES	Conventional audiometry
What test: Audio threshold via SPEAKERS	Visual Reinforcement audiometry (VRA)
How different: Conventional audiometry vs. Visual Reinforcement Audiometry	Conventional: earphones; >4yo Visual: speakers; 6mo – 2.5yo
Conventional audiometry: can perform in what ages?	>4yo
Visual Reinforcement Audiometry: perform in what ages?	Speakers 6mo – 2.5yo
What test: PHYSIOLOGIC test of COCHLEAR response to stimulation	Otoacoustic Emissions (OAE)
What test: Use in newborn to assess hearing	Otoacoustic Emissions (OAE) –physio test of cochlear response
AOM: what % resolve spontan?	50–80%
AOM: Tx for DEFINITE dx in: 0–2yo >2yo	If unilateral AOM: 0–2yo: abx >2yo: abx if SEVERE (39C, pain) Bilateral AOM --> abx
UNCERTAIN AOM: must give abx if <___ (age)	<6mo If 6mo –2yo ––> you can observe (abx if 39', severe pain)
Abx of choice for AOM?	Amoxicillin
Chronic OME: assoc w/hearing loss?	YES ––> lang delay
Chronic OME: how tx? (2 options)	watch & wait if hearing loss ––> TUBES
Rosy is an 18-month-old previously healthy baby girl who presents to clinic with congestion for three days. Today, her vitals are: T 101.2°F, BP 100/60 mmHg, P 80 bpm, RR 28 bpm. On physical exam, Rosy has clear mucus coming from both nostrils. Both turbinates show erythema. Her oropharynx is erythematous. No crackles or wheezing are heard. Mom reports that acetaminophen aids in bringing down the fever temporarily; however, the fever returns in a few hours. Mom is concerned for possible pneumonia since she was recently was given antibiotics for bronchitis. Her immunizations are up to date. Which of the following is most likely responsible for Rosy’s symptoms?	Rhinovirus Rhinovirus causes the common cold and is the most reasonable diagnosis. Rhinovirus is a very common cause of congestion and other cold-like symptoms. Rosy presents with slightly elevated temperature, slight tachypnea, and inflamed turbinates and oral mucosa. Her symptoms all correlate with the common cold.
A 14-month-old female with no significant past medical history presents to clinic with fever to 39.2 C and irritability. According to mom, the patient was initially sick one week ago with a runny nose and cough, but these symptoms had resolved. She started pulling at her ear and becoming increasingly irritable last night, with her fever spiking around 2:00 a.m. this morning. Patient is up to date on immunizations, and has had several prior ear infections. She was most recently treated last month. When you examine her ears, you observe a red, bulging tympanic membrane with limited mobility in her left ear. The exam of the right ear is normal. You are confident in your diagnosis of acute otitis media. What is your treatment plan?	Amoxicillin/clavulanate (with high-dose amoxicillin component) This choice is correct because of the severe symptoms our patient is exhibiting with a high temperature greater than 39 C. Amoxicillin/clavulanate is the treatment of choice for patients with moderate to severe otalgia or high fever, and is used for additional beta-lactamase coverage for Haemophilus influenzae and Moraxella catarrhalis, and when failure with amoxicillin is suspected.
An 18-month-old female is brought to her pediatrician by her mother who notes that she has been has been fussy for the past three days and has been pulling on her ears. The child is up to date with her hepatitis B, rotavirus, DTaP, H. influenza type B, pneumococcus, and polio vaccines. Her temperature is 102.2 F. Otoscopic exam of her left ear shows a yellow, opaque, and bulging tympanic membrane. Which of the following organisms is the most likely cause of the child's condition?	Haemophilus influenzae H. influenzae is a frequent cause of AOM (15–52% of cases). Although the child has been vaccinated against H. influenzae type B, this does not cover the unencapsulated strains of H. influenzae that cause AOM.
An 18-month-old presents with yellow and poorly mobile tympanic membranes. Four months prior he presented then with several days of nasal congestion, cough, decreased eating and ear tugging. His exam then revealed a red, nonmobile tympanic membrane and he was treated with amoxicillin. Based on the history and physical exam, what is the most likely diagnosis now?	Otitis media with effusion The earlier diagnosis of acute otitis media together with current findings of bilateral yellow and poorly mobile tympanic membranes on physical exam make this the most likely diagnosis.
An 8-year-old girl comes to the clinic with a chief complaint of a “cold” for the past two weeks. On further questioning, she developed a fever of 38.7°C, purulent nasal secretions, malodorous breath, and a nocturnal cough three days ago. Examination of the nose reveals pus bilaterally in the middle meatus, and tenderness over the mid-face. Which of the following is the most likely diagnosis?	Maxillary sinusitis The maxillary and ethmoid sinuses are large enough to harbor infection in infancy. The sphenoid sinuses do not become large enough until the third to fifth year of life, and the frontal sinuses are rarely large enough until the sixth to tenth year of life. Sinusitis is characterized by the findings in the question stem, and is often preceded by a URI. Pus draining from the middle meatus is suggestive of either maxillary, frontal, or anterior ethmoid sinusitis.
Hypernatremia: slow or rapid replace fluid?	SLOW! Decrease Na 1 mEq / 2h (10 mEq/d)
Leads to what lyte abn: Drink boiled milk	Hypernatremia
Leads to what lyte abn: Drink free H2O	Hyponatremia
How calculate: Degree of dehydration (#)	Previous wt – current wt (assumes all wt loss is free H2O)
Expect hypo/iso/hypernatremic loss: Gastroenteritis	ISOnatremia (not req to measure lytes)
Gastroenteritis: required to measure lytes?	No – only if mod/severe dehydr (assume isonatremic loss)
Dehydration: give what SIZE BOLUS over what AMT TIME? repeat boluses how often?	20 cc NS over 20–60min Repeat until normal UOP & HR
How calculate: Fluid deficit (cc) =	wt (g) x % dehydration
Dehydration: if replace fluids ORALLY ––> how many CCs per how much TIME?	5–10cc q 1–5min
Give how much maintenance fluid?: 8kg	8x100 = 800cc/d
Give how much maintenance fluid?: 14 kg	10x100=1,000 4x50=200 1,200
Give how much maintenance fluid?: 25 kg	10x100=1,000 10x50=500 5x20=100 1,600
Give how much Sodium daily? 25kg	Fluid: 10x100=1,000 10x50=500 5x20=100 --> 1,600 = 16.0 x 100ml Na: 3-4 mEq per 100ml fluid 16 x 3-4mEq = 48-64 mEq daily
Give how much Potassium daily? 25kg	Fluid: 10x100=1,000 10x50=500 5x20=100 --> 1,600 = 16.0 x 100ml K+: 2-3 mEq per 100ml fluid 16 x 2-3mEq = 32-48 mEq daily
Fluid balance: Need to replace HOW MUCH fluid for stool loss? What type of fluid?	>5g per 4h Use 1/2NS + 20KCl (no dextrose)
Normal saline: how much Na+? Cl?	154 each
Oral replacement therapy: able to use in MODERATE dehydration w/out vomit?	YES
Dehydration: when reintroduce breastmilk/full formula?	If no vomit & tolerates 1–2 ozs of ORT per feed
Johnny is a 25-month-old male who presents to the ED with a 2-day history of vomiting and diarrhea. Dad relays a history of abrupt onset of vomiting that started yesterday around 1 pm. Johnny has had 6 episodes of emesis since yesterday and 3 episodes of diarrhea. The emesis is non-bilious and the diarrhea is described as watery with specks of blood throughout the diarrhea. There are no sick contacts in the home. Vital signs: T 37.1, P 102, R 20, BP 90/60. Physical examination is normal and Johnny has still been tolerating some PO feeds without instant vomiting. What is the most immediate intervention for this patient?	no immediate intervention is necessary At this point the patient is most likely suffering from a case of viral gastroenteritis. Because he is still tolerating some PO feeds, has no obvious signs of dehydration, and has normal vital signs, there is no need for aggressive IV fluid administration or diagnostic work up. Strict return precautions should be given and it should be advised that Johnny maintains fluids as much as possible.
Rashid is a 5-week-old baby boy who presents to clinic with 4 days of repeated, forceful, non-bilious, non-bloody vomiting without diarrhea. He has 8 to 9 episodes of vomiting per day immediately following breastfeeding. The episodes started 2 weeks after the entire family suffered from severe viral gastroenteritis. His birth history is uncomplicated (full term, NSVD, unremarkable 30-week ultrasound) and birth weight was 3.6 kg (50th percentile). On exam, his vitals are: T 36.7°C, HR 185, BP 85/45, RR 36, Wt 4.1 kg (25th percentile). On exam, his eyes are moderately sunken without production of tears, his lips are cracked, and his throat is without erythema. His capillary refill is ~3 seconds, and his pulse is thready. What is your first step in management?	Intravenous lactated Ringer's solution of 20mL/kg boluses until baseline clinical status is achieved, then 100 mL/kg oral rehydration solutions over next 4 hours. Lactated Ringer’s solution or normal saline in 20 mL/kg boluses until urine output is established and mental status improves, then 100 mL/kg oral rehydration solutions over next 4 hours. This follows current CDC guidelines for treating a severely dehydrated child. Intravenous hydration with 5% dextrose ½ normal saline at twice maintenance fluid rates may be substituted for the oral rehydration solution if the child is not tolerating PO intake. To replace ongoing losses, the CDC recommends 60–120mL of oral rehydration solution per diarrheal/emetic episode (through a nasogastric tube, if necessary).
A 6-month-old male comes to clinic with a chief complaint of several weeks of vomiting after large feedings. The vomiting has become blood-streaked, which is when the mom became concerned and brought him in. The baby’s PO intake has been down and he has been losing weight. Abdominal exam is normal, with no masses palpated. What is the most likely diagnosis?	GERD regurgitation/spitting up may be difficult to distinguish from true vomiting. Infants who reflux with overfeeding may sometimes have forceful vomiting. Severe esophagitis may result in blood-streaked emesis. Pain from reflux or esophagitis may lead to feeding aversion when gastroesophageal reflux is severe
You are seeing a 1-month-old male who is < 3rd percentile for weight. He is breastfed every 2 hours and latches on well. However, he has frequent non-bilious episodes of vomiting that have been increasing over the past week despite his mother taking “reflux precautions.” He does not have mucus or blood in his stool. Physical exam reveals a small, olive-sized mass in his abdomen. What is the most likely diagnosis?	Pyloric Stenosis history of frequent vomiting, poor weight gain, and the finding of an abdominal mass are consistent with pyloric stenosis. Children with pyloric stenosis often present at 3 weeks of age.
A 15-month-old boy presents to the ED in January with a 3-day history of diarrhea. His current weight is 11 kg. He was born at 39 weeks, without any perinatal complications. There is no significant history of travel, sick contacts, or recent changes in diet. The mother notes that he has had only 2 diaper changes over the last day. Physical exam is remarkable for an irritable but consolable infant with tachycardia and normal blood pressure. He is crying without tears and his mucous membranes are dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds. He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the following statements is true?	The work-up for infectious diarrhea for this patient should include a Wright's stain for fecal WBCs, a stool Rotazyme, and a stool sample for culture and sensitivity. In addition to correcting this patient’s hydration status, a work-up for the infectious causes of this patient’s diarrhea might include a stool Wright’s stain for fecal WBCs (which would suggest a bacterial cause if this is infectious diarrhea), a Rotazyme test (given the high incidence of rotavirus in the winter months), and a stool sample for culture and sensitivity. Additional studies might include stool guaiac (for occult blood) and a check for stool C. diff toxin.
Glasgow Coma Scale (GCS): -3 categories measured? -Max score? -Score of (this) or lower requires intervention	1. Eye-opening response, Verbal response, Motor response 2. Max = 15 3. ≤ 8
DKA: see OSMOTIC DIURESES once Blood Glucose is above what #?	180
DM: screen if overweight (WHAT BMI %) and HOW MANY SXS?	BMI >85% and 2 s/sx (FHx 1–2', race, HTN, dyslipid,etc)
DM: screen beginning what age? how often?	puberty ––> q3 yrs
Diagnosis criteria for DKA: Random blood glucose > ? pH < ? Or serum bicarb < ? This is urine/blood?	Random blood glucose > 200 Venous pH <7.3, serum bicarb <15 Ketones in urine or blood
Pediatric insulin: how many injections per day? how distribute doses?	3–4 injxns/day 2/3 total in AM (1/3 rapid + 2/3 intermed) ––> 1/6 dinner (rapid) ––> 1/6 bed (intermed)
DKA: follow what LAB to monitor response to insulin?	SERUM ketones
What dz: Increased beta–hydroxybutyrate	DKA
DKA: monitor URINE KETONES how often?	Every void until no ketones
DKA: how decide when to switch from IV to SQ insulin?	Switch once NO KETONES In serum or urine
DKA: how affect BUN, CR?	Usually normal Increase if severely dehydrated
DKA: how affect: –serum Na+? –K?	HYPONATREMIA: due renal loss & osmotic movement of H2O into extracell K+ low/normal/high (despite total body hypoK) ––> provide K in IVF
DKA: admin K+ in IVF?	YES – give K+
DKA: cont insulin drip until: –pH > # –bicarb > #	pH > 7.3 Bicarb > 15
DKA: add DEXTROSE to IVF if BG <___	<300
DKA: what is tx goal: –RATE of BG drop –Target BG	Decrease 80–100 mg/dl per HOUR Goal: 120–250
DKA: #1 reason of death	Cerebral edema 2/2 overrapid glucose correction
What dz: Child w/DKA ––> give insulin drip ––> HA & mental status change ––> death	Cerebral edema 2/2 overrapid correction
Cerebral edema 2/2 overrapid correct DKA: –admin what drug to prevent?	MANNITOL IV 0.25–1mg/kgDue
Do children have lower or higher % total body H2O?	HIGHER (increases risk of dehydration)
Dehydration: low or high sensitivity?: Decreased UOP	HIGH
Dehydration: low or high sensitivity?: Dry mucus membranes	HIGH
Dehydration: low or high sensitivity?: Absent tearing of eyes	HIGH
Hypo/iso/hypernatremic dehydration: Gastroenteritis	ISO
Dehydration: correct over how many hours?: –hyponatremic –iso –hyper	Hypo: 24h Iso: 12h Hyper: 24h
How define (what serum Na+): –hyponatremic –hyper	Hypo: <130 Hyper: >150
If severe hyponatremia (<120): think what 3 etios?	1. Free H2O 2. Dilute formula 3. Adrenal insuff
Hypo/iso/hypernatremic dehydration: D.I.	Hyper (>150)
Insensible losses (evaporation) account for what % daily H2O req?	40% (other 60% is UOP)
DKA: do you replace ongoing urine loss?	NO – mobilizing extracellular fluid (you do replace stool losses)
Luanne is a 15-year-old female with 3 hours of abdominal pain and 2 episodes of non-bilious, non-bloody vomiting. She rates her pain at 8/10 and constant, located mainly in the middle of her belly, but is somewhat present throughout her abdomen. It is worse with coughing and moving. She has never had this pain before, and has had no appetite since the pain started. She is sexually active with her boyfriend of 3 months, always uses condoms, and has not been tested for STIs. Her last menstrual period was 2 weeks ago. Vitals: 37.9, HR 100, BP 120/85, RR 14. On exam, she exhibits involuntary guarding, mild rebound tenderness and tenderness to palpation between her right anterior superior iliac spin and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Her WBC and CRP are within normal limits. Based on the information above, what is the most likely diagnosis?	Appendicitis Appendicitis is the most common condition in children requiring immediate surgical intervention, but often presents differently than in adults (especially in infants). Aspects of their atypical presentation include lack of migration of pain to the RLQ, negative Rovsing’s sign, and involuntary guarding and fever without perforation. In school-age children who can articulate the pain, they often describe pain with movement or coughing (cat’s eye sign). Also, rebound tenderness was found to be neither sensitive nor specific in the pediatric population, while in the adult population it is one of the most accurate PE findings (86%). Luanne is of the older pediatric population, and so will present with a more typical appendicitis. Her sudden onset of intense pain at the umbilicus with vomiting, anorexia, and tenderness at McBurney’s point are all classic findings. The more atypical signs include diffuse pain centered below the umbilicus, and rebound tenderness that might point to a perforation (more likely, it is part of the atypical pediatric presentation given her normal WBC). Another atypical aspect of her exam is her adnexal pain during the pelvic exam, which could be due to the degree of inflammation and the positioning of her appendix. The key take away point is to have a high index of suspicion for appendicitis for pediatric patients with abdominal pain given their atypical presentation.
A 4-year-old girl with a history of type 1 diabetes mellitus was admitted to a local hospital for treatment of DKA. A few hours after the treatment, she develops grunting, tachypnea, and has vomited twice. On exam, her left eye is pointing downward and out on straight gaze. Her diastolic blood pressure is 90 mmHg. What is a likely diagnosis?	Cerebral edema Administration of bicarbonate during DKA treatment increases the risk of cerebral edema. Although symptomatic cerebral edema is rare (less than 1%), it is associated with a high mortality rate (over 20%). The signs of cerebral edema are described in the vignette, and include tachypnea, headache, vomiting, third nerve palsy, and high blood pressure.
A 9-year-old female is brought to clinic by her mother because of two days of abdominal pain and vomiting. She has vomited six times today and has had decreased appetite, but no diarrhea, fevers, sick contacts, or changes in diet. Her mom states that she has been otherwise healthy apart from increased thirst and occasional bedwetting over the last few weeks. Of note, patient’s maternal grandmother suffers from celiac disease. On exam, patient is afebrile and has a HR of 180 bpm, BP 90/60 mmHg, RR 50 bpm, and O2 saturation of 98%. She is lying in bed, appearing slightly drowsy, taking rapid, deep breaths and is slow to respond to questions. Her heart and lung exams are normal apart from being tachycardic, and abdominal exam reveals mild diffuse tenderness to palpation with no rebound or guarding. Which of the following would be the most appropriate next step in management?	Fingerstick glucose Obtaining a fingerstick glucose is the diagnostic step with the highest yield since the patient’s clinical picture is strongly indicative of diabetic ketoacidosis (DKA). DKA is a condition more closely associated with Type 1 (rather than Type 2) diabetes, and is formally diagnosed if a random glucose is > 200 mg/dL, venous pH is < 7.3, bicarbonate is < 15 mEq/L and there is ketonemia or ketonuria. Patients in DKA can present with abdominal pain and vomiting secondary to metabolic acidosis that stems from ketonemia and lactic acidosis. Furthermore, osmotic diuresis from hyperglycemia may contribute to dehydration, which can manifest as tachycardia, hypotension and altered mental status. In an attempt to compensate for the metabolic acidosis, the patient may also present tachypneic with characteristic Kussmaul respirations (rapid, deep breaths). This patient’s history of polydipsia, enuresis and family history of autoimmune disease (including celiac disease and Hashimoto’s thyroiditis) suggest that the patient has Type 1 diabetes. Her current vital signs and general state of lethargy also point towards DKA and should be confirmed with a fingerstick glucose (in addition to other tests).
A 9-year-old male presents to the ED in an ambulance after he was found unconscious at a local playground. In the ED he is arousable but extremely obtunded. He is able to minimally verbalize that his head hurts and his stomach feels uncomfortable. He states the pain is constant and non-radiating. He vomits clear liquid twice over the course of 30 minutes. Vital signs are as follows: T 37.6 C, P 66 bpm, BP 155/80 mm Hg, RR 18 bpm. You further notice that his breathing is irregular with brief episodes of apnea. On physical exam you are unable to reproduce the abdominal pain and there is no rebound tenderness or guarding. The rest of the physical exam is unremarkable. What is the most likely diagnosis?	Intracranial hemorrhage Increased ICP can be secondary to epidural or subdural hemorrhage. It is possible the patient may have fallen while playing in the playground. Increased ICP can present as the classic Cushing’s triad: hypertension, inappropriate slowing of the heart rate, and irregular respirations (Cheyne-Stokes respiration). A further complication of increased ICP is epigastric discomfort. This is caused by the elevated ICP causing vagal stimulation, resulting in the secretion of gastric acid. Lastly, the patient’s headache and non-bilious vomiting can also be ascribed to the increased ICP.
A 7-year-old boy is brought by ambulance to the ED with altered consciousness. The EMT said he found the boy in a pool of vomit. He is unable to answer questions coherently and he is alone. Physical exam findings indicate dry mucous membranes, tachypnea, tachycardia, and moaning on palpation of the abdomen. His physical exam is otherwise normal, including a normal blood pressure. What is the most likely cause of his condition?	DKA DKA typically presents with altered mentation, vomiting, dehydration, and abdominal pain. The history will yield polydipsia and polyuria during the days preceding DKA. Metabolic acidosis causes tachypnea as the body tries to blow off CO2 through a compensatory respiratory alkalosis.
A 9-year-old male is brought to the ED in a coma secondary to diabetic ketoacidosis. Which of the following laboratory results would NOT likely be found in this patient?	Potassium of 3.3 mEq/L In diabetic ketoacidosis, the acidosis and lack of insulin cause potassium to leave cells and enter the serum, causing an elevated serum potassium level. However, as the DKA is corrected and insulin is administered, the potassium will re-enter the cells, causing a decreased serum potassium level, so potassium levels should be monitored closely when therapy is initiated.
How distinguish: Trans synovitis of hip VS septic hip	DEGREE of inflamm (based WBC, ESR, CRP)
Transient synovitis of hip: Common?	YES
Transient synovitis of hip: LT sequela?	None
Transient synovitis of hip: Low or high fever?	Low
Transient synovitis of hip: Affect ROM?	DECREASED ROM
Transient synovitis of hip: How long until resolve?	3–4d
Transient synovitis of hip: How tx?	rest + ibuprofen ––> f/u 2d to recheck CBC (r/o leukemia)
Can septic arthritis lead to avasc necrosis?	Yes – accum pus ––> pressure ––> decrease BF fem head
Septic arthritis: which pathogen common in neonate?	GBS
Septic arthritis: which pathogen in adol?	N gonorr
Septic arthritis: which species of strep?	Strep pyogenes Strep pneumo
Septic arthritis: see joint warmth? redness?	Not always (since deep infxn)
Septic arthritis: joint asp has DECREASED or INCREASED viscosity?	DECREASED viscosity indicates infxn
Septic arthritis: how tx?	I & D! ––> IV abx ––> repeat asp
JRA: difference between: Pauci & polyarticular	Pauci: <4 (usu large) Poly >4 (usu small)
JRA: are all subtypes assoc w/fever?	No, only some
JRA: common to see rash?	YEs
JRA: dx requires s/sx to be present for how long?	6+ weeks
What dz: Infxn ––> Abs against joint	REACTIVE (post–infectious) arthritis (NOT transient syno: inflamm of lining – no actual Abs)
Reactive arthritis: Presents how long after initial infxn?	Few weeks
Reactive arthritis: due to what PATHOGENS: –GI infxn (2) –GU infxn –Pharyngitis	GI: Yersinia, Shigella GU: Chlam Strep
What dz: Joint pain + asp w/inflammatory cells + NEGATIVE asp cx	Reactive arthritis (contrast septic: pos asp cx)
Reactive arthritis: How tx?	ABX IF INFXN STILL PRESENT otherwise NSAIDs for few wekes
Reactive arthritis: More common lower or upper extrems? small or large joints?	Lower Small
Sprain: what anatomic injury?	Tear ligament
See SPRAIN after fall?	NO Req tearing motion
Occult fx: see how long s/p injury?	3–4w
Osteomyelitis: #1 pathogen	Staph aureus
Osteomyelitis: ACUTE or INDOLENT pain?	INDOLENT!!! Delays abx 5–10d
Osteomyelitis: what % pts present with fever but no pain?	0.5
Suspect what dz: Limp + jaw pain	Leukemia w/BM infil
An 8-year-old obese male comes to the clinic with a chief complaint of right knee pain with the right foot medially rotated. On an exam the right knee is neither swollen nor erythematous but he is noted to have a limited ROM of the right hip. In addition, when he lifts his right leg, it externally rotates. The patient did not have a URI or any trauma preceding the onset of pain. The vital signs are normal at the time of the visit and he is well appearing and afebrile. What is/are the best next step(s) in management?	AP and lateral x-ray followed up by internal reduction of the femoral head AP and lateral x-rays are needed to diagnose a slipped capital femoral epiphysis, which is considered an emergency. This patient's age group, his obesity, and the description of the external rotation of the right leg when the hip is flexed all suggest this diagnosis.
A 6-year-old female comes to the clinic with a chief complaint of worsening right knee pain over the past month. On exam, you note generalized lymphadenopathy and splenomegaly. She coughs intermittently throughout the visit, and her mother explains that she is just getting over a cold. You note absence of tenderness, erythema, effusion or warmth over the hip, knee, or ankle joints. Her vitals are unremarkable except for a low-grade fever (100.8 F). Reviewing her chart, you note that she has lost 5 lbs since her visit 2 months ago. She sits with her right leg externally rotated but appears to be in pain despite trying several different positions, refusing to bear weight on that side. What is the most likely diagnosis?	Leukemia Leukemia can present as bone pain due to replacement of bone marrow by leukemic cells. Patients may present with a limp or refusal to walk. Leukemia is associated with systemic symptoms such as low-grade fever, chronic/insidious joint pain, generalized LAD, weight loss, and/or hepatosplenomegaly.
A 3-year-old girl comes to the clinic with a limp and a slightly externally rotated right hip. Which of the following signs/symptoms would you expect in the history or exam if a diagnosis of transient synovitis were made?	History of a recent upper respiratory tract infection Transient synovitis of the hip is associated with a low-grade fever and frequently occurs during or after a URI. Between 32% and 50% of children who present with transient synovitis had a recent upper respiratory tract infection. It is also important to remember that transient synovitis is a diagnosis of exclusion, and it is important to rule out other causes of hip pain that may require urgent intervention, such as septic arthritis.
A 3-year-old female is at the pediatrician’s office for continued right knee pain after a ground-level fall six weeks ago. The patient is UTD on all immunizations, has no significant PMH, and no recent illnesses. Mom reports the patient complains of pain mostly in the morning when going to daycare but doesn’t seem to be bothered by it while playing outside in the afternoon. On exam the patient’s vitals are all within normal limits. Her physical exam reveals a well-appearing toddler who walks stiffly and avoids bending her right knee. The knee has a mild effusion but no obvious erythema. There is pain with passive flexion and extension of the right knee. During the exam the girl tells you her left ankle also hurts, which mom had forgotten about but says started hurting the same time as the right knee. Her CBC is normal, while her ESR and CRP are mildly elevated. Which of the following is the most likely cause of this patient’s condition?	Juvenile idiopathic arthritis Pauciarticular juvenile arthritis is the most common type of JIA (60% of JIA) and causes pain in four or fewer joints for six or more weeks. This patient is generally well even after six weeks of pain, which would be unlikely if this patient had septic arthritis. Her pain improves with activity, and the ESR/CRP are only mildly elevated. On exam, she has a mild effusion but no obvious erythema. In cases of systemic JIA, patients may have a rash which lasts only a few hours (evanescent) that is also macular and salmon, and high-spiking and appears periodically (once or twice a day); however, this form of JIA is not consistent with this patient’s history.
A 4-year-old child is refusing to walk over the course of a week. Her mother recalls that she fell off her bike yesterday. On exam, she is afebrile, but has decreased ROM of her hip. You review her file and note that she is up-to-date on her immunizations and she was last seen three weeks ago for a self-limited episode of diarrhea that she developed while visiting family in rural Mexico. Aspiration of her affected hip joint reveals slight increase in inflammatory cells but normal chemistries and a negative gram stain. Culture is pending. Which of the following is the most likely diagnosis?	Reactive Arthritis The patient likely had a recent case of mild to moderate gastroenteritis in Mexico, which may have been secondary to an bacterial enteritis such as shigella, or campylobacter. In reactive arthritis, joint inflammation occurs a few weeks later because antibodies made during the illness are attacking the joint. While several inflammatory cells would be seen in the aspirate, importantly, the cultures will turn out to be negative.
VSD: why not present in neonate?	High pulm vasc R in neonate ––> no reason for blood to shunt to pulm vasc rather than systemic
VSD: how result in poor feeding?	LV overload ––> CHF ––> increased RR ––> difficult feeding
What dz: Sweat during feed; tire during feed	CHF (e.g. 2/2 VSD)
CHF: #1 phys finding	TACHYPNEA
What dz: Tachycardia w/gallop rhythm	CHF
VSD: is murmur intensity correl with size of defect?	NO
What MURMUR: Loud, blowing holosystolic at LLSB	VSD
VSD: when present?	Few days s/p birth
VSD: where best ausc?	Lower left sternal border
VSD: does magnitude of shunt affect the age of presentation?	YES larger defect ––> earlier CHF
VSD: defect becomes smaller or larger with time?	SMALLER (75% small & 50% total will close)
VSD: what % total close?	50% (75% small VSDs)
VSD: expect abn EKG?	YES – see RV dominance
4 defects that cause murmur AND CHF	1. VSD 2. Ao stenosis 3. Ao coarct 4. large PDA
Lead to CHF?: PDA	Yes (if large)
Lead to CHF?: ASD	No
Lead to CHF?: TOF	No
Infant CHF: req inpatient tx?	YES
How tx: –CHF due VSD –CHF due cardiomyopathy	VSD: digoxin + furesomide Cardiomyo: ACE–I
VSD: decide surgery at what age?	6mo
Gallop: common in peds?	No
What murmur: Continuous diastolic murmur	PDA (PATHOLOGIC)
Common or rare?: Endocarditis	Rare
Common or rare?: Cardiomyopathy	Rare
Innocent murmurs: common what age? due to defect?	3–7yo NOT defect (due vibration)
#1 innocent murmur	Still's
What murmur: musical, vibratory murmur in LSB while supine	Still's (innocent)
Still's murmur: best heard standing or supine?	SUPINE
What murmur?: Widely split, fixed S2	ASD
ASD: presents what ages?	3–5yo (contrast VSD: few days s/p birth)
What murmur: Presents 3–5yo	ASD
What murmur?: Initially syst ejection murmur ––> early diast murmur	Ao stenosis (leads to Ao insuff)
What murmur?: S1 ––> systolic ejection click ––> harsh systolic murmur	Pulmonic stenosis
PDA: louder in dias or syst?	SYST loudest (although continuous)
What murmur?: Holosystolic, blowing	VSD
What murmur?: PROGRESSIVE; detect any age; p/w HTN in upper extrems	Ao coarct
Detect what age: Bicuspid Ao valve	Adol/adult
1st & most subtle sign of inadequate circulation	tachycardia
Femoral pulse: represents periph or central pulse?	Central (sim carotid)
A 1-month-old African-American male presents to your office for a check-up. The baby was born at term by NSVD to a 29-year-old G1P0 mother with no complications. Mother states the baby was feeding well until a week ago, when he developed increased sleepiness, prolonged feeding, and greater duration between feeds. His mother notes he stops to take breaks sometimes because he seems to be trying to catch his breath. He has 4 to 6 wet diapers per day and poopy diapers 3 or 4 times per day. Vital signs are: T: 37.6 C, RR: 68 bpm, P: 138 bpm, BP: 88/58 mmHg, and 02 saturation is 98%. The physical examination is notable for increased respiratory effort and retractions, and, upon cardiac examination, a murmur with a hyperactive precordium and no cyanosis. Abdominal exam reveals a liver edge palpable to 4 cm below the right costal margin. Which condition would be least likely to be the cause of the patient’s symptoms?	Atrial Septal Defect atrial septal defects (ASDs) do not cause CHF. An ASD malformation is a left-to-right shunt, and—depending on the size of the defect—the patient may or may not present with symptoms. ASDs often go undiagnosed for decades due to subtle physical examination findings and/or a lack of appreciable symptoms. If the defect is large enough, pediatric patients may present with easy fatigability, recurrent respiratory infections, or exertional dyspnea.
A 3-week-old infant is brought to the pediatrician for failure to thrive (despite adequate, even prolonged, feedings) and respiratory distress (particularly tachypnea). EKG shows high voltage QRS complexes in leads V1 and V2. What other features does this infant most likely have?	Lef to right shunt A heart murmur from a VSD is typically not appreciated in the immediate newborn period, as the pulmonary vascular resistance is still quite elevated. During this time, since the pulmonary vascular resistance equals the systemic vascular resistance, there is no shunting of blood through the open VSD. However, after a few days to weeks after birth, the pulmonary vascular resistance decreases, and the murmur appears, reflecting the shunted flow of blood through the open VSD (from left to right).
You have accepted a part-time tutoring job for first-year medical students. One of your students asks if you would please clarify the details of normal fetal circulation. Which of the following best describes the path of the majority of the blood that enters the right atrium?	RA > RV > ductus arteriosus > systemic circulation The majority of the fetal circulation travels this route. Approximately 90–92% of the blood that enters the RV (two-thirds of the blood that enters the RA) travels out and through the ductus arteriosus, bypassing the pulmonary circulation and the left heart, ending up in the descending aorta. This blood is perferentially less oxygenated than that which flows through the foramen ovale. Like the foramen ovale, closure of this bypass is a normal transition from intra to extrauterine life.
A 5-year-old boy is noted to have a grade II systolic murmur and a widely split S2 murmur on cardiac exam. His vital signs are stable and he has been asymptomatic. Which of the following statement is accurate regarding this patient’s presentation and likely condition?	This patient's murmur is caused by flow through the pulmonary outflow tract and should be evaluated This patient’s murmur is likely caused by an atrial septal defect, which causes flow of additional blood through the pulmonary outflow tract and should be evaluated.
Cerebral palsy: Progressive?	No
Cerebral palsy: Defining feature	Decreaesed motor control
Cerebral palsy: is spasticity dependent on velocity?	YES – greater resistance w/rapid movement
Cerebral palsy: is resistance greater with SLOW or RAPID movement?	RAPID
Cerebral palsy: in/decreased tendon jerks	INCREASED
What dz: See spastic diplegia	C.P.
Name for: Increased tone, esp in lower extrems	Spastic diplegia
Spastic diplegia: assoc w/prematurity?	Yes
Leads to what TYPE of cerebral palsy: –birth asphyxia –kernicterus	Both lead ot DYSKINETIC cerebral palsy (NOT other types)
Cerebral palsy: see pts with GLOBAL developmental delay?	No – just motor GDD = cogn disabl/MR
MR/cognitive disability: possible to see FHx?	Yes – if 2/2 inborn error metab
Abn development 2/2 neglect: See improvement if stop abuse?	YES
Do premature babies have increased risk of abuse?	Yes
Myopathy: p/w gross or fine motor abns?	BOTH
What class of dz: abn tone, fasciculations, weakness	Myopathy (NOT CP – see spasticity, increased tendon jerks)
Cerebral palsy: how dx?	MRI & assessment by developmental specialist (use Bayley scales of infant development) (determines etio of abn neuro exam)
What dz: Upslanted palpebral fissures	Downs
What dz: –small ears –low–set ears	Small: Downs Low: Turner's
What dz: Epicanthal folds	Downs
What dz: Redundant nuchal skin	Downs
#1 M.R. involving genetic material	Downs (21)
Down's: 3 genetic mxns	Trisomy (#1, regardless mat age) Unbalanced translocation Mosaic for 21
Down's: ABSOLUTE risk higher in young or old mothers?	YOUNG (relative risk higher in old)
Downs: how dx?	Leukocyte karyotype
What dz: Micropthalmia, microceph, polydact, cleft lip & palate, umbilical hernia, CUTIS APLASIA	Patau (13)
Patau (13): defects in what organs? (2)	Cardiac Renal Also: microceph, polydact, clefts, umbilical hernia, cutis aplasia
#1 FAMILIAL cause of M.R.	Fragile X
Fragile X: what repeat?	CGG outside FMR1 coding regions
What dz: larges testes; large everted ears; long face w/large mandible	Fragile X
Turner's syndrome: see physical differences at birth?	Yes
What dz: See lymphedema in utero	Turner XO
What dz: web neck, low ears, hyperconvex nails, shield chest	Turner XO
Turners: What is feature of nails?	Hyperconvex
Turners: Ao coarctation in what %?	0.2
Turners: How affect IQ?	NORMAL IQ
How dx: Benign Neonatal Hypotonia	Dx of EXCLUSION
Benign Neonatal Hypotonia: px?	Good; gradual increase tone
Down's: what is most consistent finding at birth?	HYPOTONIA ––> poor feeding
Down's: recommended imaging at birth?	ECHO
Down's: recommended blood test?	TSH (6mo ––> q 1 year)
Down's: what skeletal abn?	Atlanto–axial instab
Down's: predisp what cancer?	Leukemia
Hypotonia in infant: Tend to FLEX or EXTEND extrems?	Extend (passive) (noxious stim ––> won't flex)
Hypotonia in infant: see in/decreased primitive reflexes?	DECREASED (since hypotonic)
Hypoxic–ischemic encephalopathy 2/2 perinatal injury: more commonly see HYPO or HYPERtonia?	HYPER (although can see hypo)
Suspect what dz: Normal neonate ––> 2–4w later see lethargy, fever, HYPOTONIA	SEPSIS 2/2 GBS
#1 etio ambiguous female genitalia	Congen Adrenal Hyperplasia
Congen Adrenal Hyperplasia: how inherit (pattern)?	AR
Congen Adrenal Hyperplasia: defect what hormone?	Cortisol synth
Congen Adrenal Hyperplasia: #1 type	21–OH deficiency Decrease cortisol, aldo Increase 17–OH progest ––> increase androgens
21–OH deficiency: –decrease production which hormones? (2) –increase production which hormone? effect?	Decrease cortisol, aldo Increase 17–OH progest ––> increase androgens ––> verilize fems
Difference b/w: CLASSIC and NONCLASSIC congen adrenal hyperplasia	Classic: complete enz def ––> adrenal crisis ––> hypoNa, hyperK ––> shock at 1–2w Nonclassic: NON–VIRILIZING; partial enz def ––> manifests under stress
Classic CAH: sxs appear what age?	1–2w
CAH: what lyte abns? (2)	HypoNa+ HyperK+
Non–classic CAH: virilizing?	NO partial enz def ––> manifests under stress
See proteinuria with: –acute glomerulonephritis? –intersitital nephritis?	YES BOTH – but not as high as nephrotic syndrome
What dz: 1+/2+ protein during FEVER or EXERCISE	Benign proteinuria
Benign proteinuria: how define?	1+/2+ protein during fever or s/p exercise
What dz: Only excrete protein when standing (1,500mg/d)	Orthostatic proteinuria
Orthostatic proteinuria: indicate renal dz?	NO – common in adols
Orthostatic proteinuria: see in AM?	NO – first AM urine should be negative since lying down ––> not spillling protein
Common to see generalized tonic–clonic szs in newborn?	NO – contrast older infants
Neonatal sz: see horizontal or vertical deviation?	Horiz
Suspect what phenomenon: Neonate w/eye jerking, lip–smacking, tonic limb posturing, APNEA	SEIZURE (subtle s/sx)
Ankle clonus: what is normal # beats?	<10
Clonus: what is abn # beats in a 1–2mo old?	>3 beats is abnormal
Indicates what process: –schistocytes –helmets	Hemolysis (both)
Nephrotic syndrome: –what age? –M or F?	1.5–8yo M >F
Nephrotic syndrome: #1 etio	MCD
Nephrotic syndrome: Fluid moves from ___ to ____	Lose albumin in urine –––> Fluid moves from VASC to INTERSTITIUM ––> hypovolemia
Nephrotic syndrome: How affect BP?	NORMAL BP Retain H2O but fluid moves out of vasc into interstitium
How affect BP: –Nephrotic syndrome –Acute glomerulonephritis	Nephrotic: normal BP Acute GN: HTN
Acute glomerulonephritis: #1 presenting s/sx	Tea colored urine
Nephrotic synd and/or acute glomerulonephritis: Gross hematuria	acute nephritis
Nephrotic synd and/or acute glomerulonephritis: preceded by URI	acute nephritis
Nephrotic syndrome: what lyte change? 2 mxns for change	HYPONATREMIA 1. Lose vasc fluid to interstitium ––> retain excess H2O & Na in kidney 2. HYPERLIPID ––> pseudohyponatremia
Nephrotic syndrome: how affect cholesterol?	Lose albumin in urine ––> Liver increases lipid production ––> HYPERCHOLESTEROL (also see decreased lipid clearance from circ)
Nephrotic synd: Consider what imaging?	Renal U/S
Nephrotic synd: order C3/C4?	Yes – r/o collagen vasc dz
Nephrotic synd: Order what test to r/o post–strep glomerular dz	Streptozyme
Nephrotic synd: Tx w/albumin infusion in what 2 scenarios?	1. Ascites/effusion ––>resp problems 2. Scrotal edema
Nephrotic synd: Can you tx with diuretic monotherapy? How admin?	Albumin infusion ––> THEN intravenous furesomide *Never diuretic alone ––> hypovol
Nephrotic synd: Steroids useful?	Yes
Nephrotic synd: How much salt per day?	restrict 1,500 – 2,000 mg daily
Nephrotic synd: Admin what ppx vaccine	PCV
Nephrotic synd: what 2 drugs prevent relapse?	cyclophosphamide x 8–12w Calcineurin inhibitor (tacro, cyclospor) x 2 years
Nephrotic synd: See what complication (esp if tx with steroids)	Spontaneous peritonitis
Nephrotic synd: Most common pathogen in spont peritonitis (comp)	Strep Pneumo (also GNs)
Nephrotic synd: Do minority or majority kids outgrow?	Majority
PID: what age?	15–19yo F
PID: G&C ––> also infect uterus w/what 4 pathogens?	1. E coli 2. Bacteroids 3. Mycoplasma 4. Ureaplasa
What dz: 16yo F with suprapubic pain ––> RUQ pain radiating to R shoulder	Fitz–Hugh–Curtis (2/2 PID)
PID: is pain most commonly uni/bilat?	BILAT
PID: order what tests?	Cervical cx Urine PCR
PID: req to tx partners?	Yes
Low or high fever?: Appendicitis	Low
Low or high fever?: Acute cholecystitis	Low
Low or high fever?: Pneumonia	HIgh
Low or high fever?: UTI	High
Low or high fever?: Septic cholangitis	HIgh (contrast acute cholecystitis: low)
Low or high fever?: Gyn infxn (e.g. PID)	High
Hypo–, normo– or hyperactive bowel sounds: Ileus	Hypo
Hypo–, normo– or hyperactive bowel sounds: Gastroenteritis	Hyper
Hypo–, normo– or hyperactive bowel sounds: SBO	Hypo <––> high–pitched hyper (peristalsis)
What dz: Bowel sounds: quiet ––> high–pitched and hyper ––> quiet	SBO w/peristalsis
Abd exam: what does hyperresonance indicate?	Gaseous distension
What dz: Involuntary guarding	Peritonitis
Hepatitis: –see vomit? diarrhea? –fever? –mandatory finding?	Vomit; no diarrhea Fever Usu see JAUNDICE
Hepatitis: well–localized or vague abd pain?	Vague (sometimes RUQ)
What dz: Epigastric pain radiating to back	Pancreatitis
Pancreatitis: –vomit? –diarrhea?	Vomit yes Diarrhea no (same as hepatitis, appenditicits)
Appendicitis: –vomit? –diarrhea?	Vomit yes, diarrhea no (same as hepatitis, pancreatitis)
Does sexual debut affect risk of UTI?	Yes – increased risk at debut
Low or high fever: Ectopic pregnancy	TRICK – no fever
What dz: Acute INTERMITTENT sharp abdominal pain radiating down extremitin; n/v	OVARIAN TORSION
Ovarian torsion: is pain intermittent or constant	INTERMITTENT
Ovarian torsion usually idiopathic or 2/2 cyst/neoplasm?	2/2 cyst/neoplasm
Ovarian torsion: –vomit? –diarrhea?	Vomit no diarrhea
Ovarian torsion: see bilateral torsion?	See bilat in INFANT
Testicular torsion: what finding on phys exam?	Lose cremasteric
Testic torsion: irrevers damage after how long?	4h
Crohn's: 1st line drug	Mesalamine (5–ASA)
Mesalamine (5–ASA): 1st line in what dz?	Crohn's
Infliximab: what dz?	IBD
What dz: Chronic abd pain + bloody stools + failure to grow	IBD
IBD: is pain localized?	YES (red flag)
IBD: does pt p/w urinary sxs?	DYSURIA
IBD: will pain awaken pt from sleep?	Yes
IBD: what % pts have positive FHx?	0.3
IBD: what CBC abnormalities? (2)	Anemia HIGH PLATELETS
IBD: see hypo or hyperalb?	Hypo
IgA tissue transglutinase Ab (TTG): sens? spec?	Sens & spec for celiac
Tissue transglutinase: what CLASS of Ab? (Ig_)	IgA
Celiac: un/common?	Uncommon
What dz: 6mo–2yo with chronic abd pain + ABDOMINAL DISTENSION + vomit/diarrhea + NO GROSS BLOODY STOOLS	Celiac dz
Celiac dz: what is youngest age you may see?	6mo!
Celiac: see gross blood loss? occult?	OCCULT ––> anemia (no gross BRBPR)
Peptic ulcer dz: common in child?	NO
Peptic ulcer: see diarrhea? gross bloody stool?	NO – p/w pain & occult loss
#1 intestinal PARASITE in US	Giardia
Giardia: best dx test?	SPECIFIC ANTIGEN TEST (NOT O&P)
What dz: Abdominal pain & palpable mass & bloody streaks on stool & guaic pos	Constipation
HSP: –diarrhea?	NO Although most pts p/w collicky pain & bloody stools
What dz: Collicky abdominal pain + bloody stools + RASH + no diarrhea	HSP
HSP: abd pain is constant or intermittent?	COLLICKY
#1 etio chronic abdominal pain in child	Functional abd pain (dx of exclusion)
Functional abd pain: see bloody stool?	NO – if blood ––> cannot be fxnl
Functional abd pain: how tx?	Reassurance
IBD: 1st imaging test to perform? 2nd? risks?	Colo ––> THEN barium enema (delays colo) UC: enema ––> increase risk toxic megacolon
#1 intestinal PARASITE in US	Giardia
Giardia: best dx test?	SPECIFIC ANTIGEN TEST (NOT O&P)
What dz: Abdominal pain & palpable mass & bloody streaks on stool & guaic pos	Constipation
HSP: –diarrhea?	NO Although most pts p/w collicky pain & bloody stools
What dz: Collicky abdominal pain + bloody stools + RASH + no diarrhea	HSP
HSP: abd pain is constant or intermittent?	COLLICKY
#1 etio chronic abdominal pain in child	Functional abd pain (dx of exclusion)
#1 intestinal PARASITE in US	Giardia
Functional abd pain: see bloody stool?	NO – if blood ––> cannot be fxnl
Giardia: best dx test?	SPECIFIC ANTIGEN TEST (NOT O&P)
Functional abd pain: how tx?	Reassurance
What dz: Abdominal pain & palpable mass & bloody streaks on stool & guaic pos	Constipation
IBD: 1st imaging test to perform? 2nd? risks?	Colo ––> THEN barium enema (delays colo) UC: enema ––> increase risk toxic megacolon
HSP: –diarrhea?	NO Although most pts p/w collicky pain & bloody stools
What dz: Collicky abdominal pain + bloody stools + RASH + no diarrhea	HSP
HSP: abd pain is constant or intermittent?	COLLICKY
#1 etio chronic abdominal pain in child	Functional abd pain (dx of exclusion)
Functional abd pain: see bloody stool?	NO – if blood ––> cannot be fxnl
Functional abd pain: how tx?	Reassurance
IBD: 1st imaging test to perform? 2nd? risks?	Colo ––> THEN barium enema (delays colo) UC: enema ––> increase risk toxic megacolon
#1 intestinal PARASITE in US	Giardia
Giardia: best dx test?	SPECIFIC ANTIGEN TEST (NOT O&P)
What dz: Abdominal pain & palpable mass & bloody streaks on stool & guaic pos	Constipation
HSP: –diarrhea?	NO Although most pts p/w collicky pain & bloody stools
What dz: Collicky abdominal pain + bloody stools + RASH + no diarrhea	HSP
HSP: abd pain is constant or intermittent?	COLLICKY
#1 etio chronic abdominal pain in child	Functional abd pain (dx of exclusion)
Functional abd pain: see bloody stool?	NO – if blood ––> cannot be fxnl
Functional abd pain: how tx?	Reassurance
IBD: 1st imaging test to perform? 2nd? risks?	Colo ––> THEN barium enema (delays colo) UC: enema ––> increase risk toxic megacolon
What dz: Cobblestone mucosa of GI tract	Crohn's
What dz: GI mucosa friable & erythematous	UC (contrast Crohn's – cobblestone)
What dz: GI PSEUDOPOLYPS	Ulcerative Collitis
CD or UC: ALWAYS involves rectum	UC
Sickle cell: –what AA substitution? –which Hgb chain?	Switch VAL to GLUTAMIC ACID Beta chain
Sickle cell: De/increase retic count?	INCREASE retics
What electrophoresis pattern in: –fetus ––> normal adult –sickle TRAIT –SCD	Normal: FF ––> AF Trait: FSC (mild sickling) Dz: FS
What dz: electrophoresis shows: FSC	sickle TRAIT (dz: FS)
What dz: electrophoresis shows: FS	Sickle DISEASE (trait: FSC)
Sickle cell: –what is baseline color of pt? –what does pallor indicate?	Baseline jaundice (2/2 hemolysis) Pallor due: spleen sequestor RBCs and/or aplastic crisis
Sickle cell: Murmur?	Flow murmur 2/2 anemia
Sickle cell: Is parental monitoring of spleen effective ppx?	YES
Sickle cell: How evaluate for stroke? (what test)	Transcranial Doppler
Sickle cell: What UA finding?	Hematuria 2/2 papillary necrosis
#1 death in sickle pts	Acute chest synd
What dz: Sickle pt with fever, cough, SOB, hypoxia	Acute chest syndrome
Acute chest syndrome: Single or multiple lobules affected?	Multilobular
Acute chest syndrome: How appear CXR?	NEW INFILTRATES; effusion, atelectasis
Acute chest syndrome: Specific etiology identified in what % pts?	40% Often develops in child hospitalized for painful vasooculsion crisis
What complication: –Sickle + chest pain + decreased breath sounds –Sickle + CP + normal bs	Decreased bs: ACS Normal bs: Rib infarct
What complication: Sickle + cardiomegaly + lower lobe infiltrates + tachypnea; no chest pain	CHF (2/2 chronic anemia)
Aplastic crisis in sickle: may be due what infxn?	Parvo B19
Sickle: is EVERY fever an emergency?	YES – may be only sign of serious infxn
Sickle: susc to what 3 pathogens?	Strep pneumo H flu N mening
Sickle: what gallbladder complication?	Cholelithiasis (often perform lap chole BEFORE develop gallstones)
Sickle: see precocious puberty?	NO – see delayed sex maturation
Sickle: why do pts snore?	Fxnl asplenia ––> hypertrophy WALDEYERS RING
Sickle: what eye dz?	Proliferative retinopathy
Sickle: ppx lap chole?	YES – remove GB before develop G–stones ––> infxn
Sickle: cure?	BMT
Sickle: tx w/what drug?	Hydroxyurea
Hydroxyurea: tx what dz?	Sickle (decrease freq & severity)
Sickle: give what vaccines if: –<2yo –>2yo	Hib ALL pts <2yo: PCV–23 >2yo: PCV–13 (polysacch)
Sickle: –if sepsis ––> what abx? –what age initiate ppx?	Penicillin Start ppx at 5–6yo
0–4mos: infant gains how much wt per day?	20–30 g/d
Malnutrition: decreased HC is early or late finding?	LATE (brain usu spared)
FTT: definition: –wt <____% –wt for height <___%	Wt <3% Wt for ht <3%
FTT: what % cases are NON–organic?	0.9
How present: (what finding) True milk–protein allergy w/FTT	BLOODY STOOLS
Lead level: –toxic –acute encephalopathy (#)	Toxic >10 Encephalo >100–150
Lead: suspect in what 2 types houses	<1950 Renovatd 1978
Lead screen: screen CAP or VENOUS?	CAPILLARY lead level ––> confirm w/venous
Lead: universal screen in what 2 scenarios (community scenarios)? Screen what ages?	1. Prevalence >11% 2. >25% houses older than 1950 Screen 9–12mo ––> repeat 2yo
What dz: Microcytic anemia w/stippling	Lead poison
Lead poison: micro/normo/macrocytic anemia?	Micro
Lead poison: how affect: –BP –pulse –rr	Increase ICP ––> CUSHING HTN bradycardia resp distress
Lead: see hypo or hyperphosphatemia?	HYPO
What dz: Hypophosphatemia + urine coproporphyrin + glycosuria	Lead poison
Lead poison: see what molecule in urine?	Coproporphyrin
What dz: CXR: hyperdense flecks	Lead poison
Tx what dz: Dimercaprol	Lead poison
Tx what dz: Calcium EDTA	Lead poison
Tx what dz: Succimer	Lead poison
Tx what dz: Penicillinamine	Lead poison
Lead poison: admit to hosp if lead what level?	>100 + sxs
Lead poison: how tx (what drugs): –inpt (2) –outpt (2)	Inpt: 1. Dimercaprol 2. INTRAVENOUS Ca2+ EDTA Outpt: 1. Succimer 2. Penicillinamine
What drug: Stims vomit center in brain ––> vomit w/in 20 minutes	Ipecac
Ipecac: –mxn –how long until vomit? –useful if poison w/in what time frame?	Stims vomit center in brain ––> vomit in 20 mins Useful if poison <30min
Ipecac: need to consult poison center first?	YES
Ipecac: contra–indicated in what age?	<6mo
Ipecac: contraindicated if infant ingests: –LOW or HIGH viscosity hydrocarbon?	LOW
Ipecac: safe to use in pt w/coagulation disorder?	No – contraindicated
Poisoning: Perform gastric lavage?	No clinical benefit
Activated charcoal: Useful w/in how long from poison ingestion?	<1hr
Toxin ingestion: see fever?	Usu not
Reye's syndrome: affect ICP?	Increase ICP ––> papilledema, change mental status ––> diffuse encephalopathy
Metabolic dzs: p/w fever? Focal neuro findings?	No fever or focal neuro P/w diffuse encephalo
ICH: focal or diffuse neuro?	FOCAL
Meningitis: see papilledema? focal neuro s/sx?	NO
Seizure disorder: see what lyte abns? (2)	Low Ca Low Mg
Infant with mental status change: if high suspicion of etiology ––> is head CT mandatory?	YES – GET HEAD CT
Cystic fibrosis: How inherit? How many mutations?	AR 1,500 mutation
Cystic fibrosis: Deficiency in what enzyme responsible for malabsorption?	Defic lipase
Cystic fibrosis: Admin what % daily recommended cals?	120–150%
Recommended daily calories (kcal/kg/d): –9w normal –9w cystic fibrosis	normal: 100 kcal/kg/d CF: 130–160
Cystic fibrosis: What % calories should be fat?	40% (contrast normal: 30%)
Cystic fibrosis: Do minority or majority of teens develop CHRONIC PNA?	MAJORITY
Cystic fibrosis: Replace what 3 enzymes? 4 vitamins?	Lipase Amylase Protease (Creon) vitamin ADEK
Cystic fibrosis: Sweat test ––> how long until results?	DAYS
Cystic fibrosis: MAIN dx test	Sweat test (genotype is adjunctive) (>60 is diagnostic)
Sweat chloride test: –normal –CF	Normal <60 >60 diagnostic
Cystic fibrosis: Is genetic test diagnostic?	NO – req further testing (preferably sweat test)
Cystic fibrosis: Vitamin E deficiency ––> what complication?	HEMOLYSIS
Cystic fibrosis: Hemolysis due to what deficiency?	Vitamin E deficiency
Cystic fibrosis: In/decreased haptoglobin?	DECREASE (due hemolysis 2/2 vit E def)
Cystic fibrosis: –in/decrease plts? –retics?	Hemolysis (2/2 vit E def)––> –increase plts –increase retics
#1 bowel obstruction in 6mo–6yo	Intusseption
Intussception: what ages? 80% <___yo?	6mo – 6yo 80% <2yo
Intussception: M or F?	M>F
Intussception: which invaginates into other – prox vs. distal	Prox ALWAYS invaginates into distal
Intussception: intermittent or constant pain?	PAROXYSMS of pain
What dz: paroxysmal abd pain + inconsolable + sausage in R abd	Intussception
Intussception: vomit? diarrhea?	Vomit: YES Stool is CURRANT (blood & mucus)
Intussception: most common location	Ileocecal jxn
Intussception: underlying mxn (what stimulates telescope)?	Hypertrophied lymph tissue
Intussception: what dx imaging (2)?	Air or contrast enema
Name for: Edges of optic disc blurred; narrow BVs	Papilledema
TTH or Migraine: LATE in day	TTH
TTH: occur AM or PM?	PM
TTH or Migraine: Triggered by stress	BOTH
TTH or Migraine: Occipital	TTH
TTH or Migraine: Tender neck muscles	TTH
TTH or Migraine: BILATERAL	TTH
TTH or Migraine: Any time of day	Migraine
Migraine: AM or PM?	Any time of day
TTH or Migraine: Unilateral	Migraine
TTH or Migraine: Can be triggered by foods	Migraine
TTH or Migraine: Relieved with sleep	Migraine
What type of HA: Bilateral vision changes + parasthesias + mental status changes	BASILAR migraine
Basilar migraine: how present?	Bilateral vision loss Parasthesias Mental status change
Suspect what type of pathology: HA + developmental delay	Intracranial process
Febrile szs: Occur EARLY or LATER in course of fever?	EARLY (1st day)
Febrile szs: See with temp >___ C	>38C
Febrile szs: Consider LP if <___ (age)	1st sz <12yo (OR atypical sz w/slow return to baseline)
SIMPLE or COMPLEX febrile sz: More common	Simple
SIMPLE or COMPLEX febrile sz: GENERALIZED	SIMPLE!!! (complex is focal)
SIMPLE or COMPLEX febrile sz: <15mins	Simple
What is difference: Simple vs. Complex febrile sz	Simple: <15min x 1; generalized Complex: >15min x multi; focal
Febrile sz: what is % recurrence if 1st sz: –<12mo –>12mo	<12mo: 50% recurrence >12mo: 30% recurrence
Febrile sz: increase risk epilepsy?	SLIGHT increase (esp if early & recurrent)
Febrile sz: FHx?	Yes
True seizure: see PINPOINT or DILATED pupils?	Pinpoint
What % infants w/meningitis p/w szs?	0.3
Can a BENIGN VIRAL SYNDROME be responsible for fever without source?	YES (may be indisting from occult bacteremia)
#1 pathogen in OCCULT BACTEREMIA	Strep pneumo
Infant with fever of unknown source: catheterize if: –M <__(age) –F <__(age)	M<6mo (after 6mos start to think less about occult UTI) F<12mo
What % infants w/bacterial meningitis have fever?	0.95
Infant w/bact meningitis: top 2 pathogens in IMMUNIZED: –<2mo –2mo – 12yo	<2mo: E coli & GBS 2mo–12yo: Strep pneumo + N mening
Bact meningitis: suspect GBS if under what age?	<2mo
Bact meningitis: initiate what abx?	IV cephalo + vanco
Bacterial meningitis: may lead to what HORMONAL complication?	SIADH
Bact meningitis: is it RARE or COMMON for txed mening to be fatal?	RARE
#1 VIRAL meningitis	Enterovirus
Viral meningitis: what cells predom CSF: –0–48h –>48h	0–48h: PMNs >48h: lymphocytes
Viral meningitis: see predom LYMPHOS in CSF after how many hours?	>48h
Viral meningitis: what VIRUS ––> RBCs in CSF?	HSV
HSV meningitis: what CSF feature?	See RBCs
Shock: initial bolus (size & fluid)	20 cc ISOTONIC NS
Shock: When initiate INTRAOSSEOUS access?	Fail periph: 90 seconds or 3 attempts
IV access in SHOCK: What TYPE of central line is an approp alternative to periph line in older child	FEMORAL (NOT subclavian or arterial)
Meningococcemia: 1st choice abx	IV PENICILLIN
Meningococcus: how prophylx: –adult contacts –children	Adult: cipro Children: rifampin
Meningococcemia: admin what abx at discharge to elim carrier state?	CEFTRIAX
MCV4: safe what ages?	11–18yo
Meningococcemia: –what % adols die? total die? –what % have comps?	Fatal 25% adols, 10% total 10–20% comps
Dehydration: when reintroduce breastmilk/full formula?	If no vomit & tolerates 1–2 ozs of ORT per feed
Where is pathology: BILLIOUS vomit	POST–AMPULLA
Where is pathology: Bloody vomit	Above ligament of Treitz
#1 etio gastroenteritis	Rotavirus
Pyloric stenosis: When present?	3w (1w – 5mo)
Pyloric stenosis: Bilious?	No – immed vomit
Pyloric stenosis: Where palpate olive?	Above & right umbilius
Pyloric stenosis: See skin changes?	Often see jaundice
Pyloric stenosis: What lyte abn?	Hypochloremic metabolic alkalosis
Pyloric stenosis: What imaging? (2)	Abd U/S ––> (if not avail) ––> upper GI WITH CONTRAST
What dz: Upper GI: STRING SIGN	Pyloric stenosis
Pyloric stenosis: Does LACK of palpable olive ––> affect suspicion?	YES ––– speaks strongly AGAINST P.S.
Pyloric stenosis: See diarrhea?	No
UTI: see vomit? diarrhea?	Vomit yes, no diarrhea –– may see loose stools
Gastroesoph reflux: see poor wt gain?	Baby can develop food aversion ––> FTT
Baby w/normal growth ––> acute vomit: Suspect metabolic disorder?	Not if previously normal growth
HSP: –peaks what age? –M or F?	4–6yo (range 2–17) 2x M > F
HSP: underlying mxn?	viral/bact URI (50% pts )–––> IgA–mediated
HSP: how affects platelts?	NORMAL PLATELETS!!!!
What dz: URI ––> IgA deposition ––> leukocytic vasculitis	HSP
What dz: erythematous macules/wheals ––> petechiae ––> purpura	HSP
HSP: where see purpura? (distrib)	Gravity–dependent & pressure–sensitive areas ELBOWS, LOWER EXTREMS
HSP: what % pts have skin s/sx?	1
HSP: order what 2 labs?	UA: ALWAYS; assess renal involve (if see blood/protein ––> order BUN, CR) CBC: see NORMAL PLATELETS
HSP: see splenomeg?	No
HSP: req PT? PTT? Blood cx?	NO
HSP: –resolves how long? what % recur? –how tx? –risk what GI comp?	4–6w; 30% recur NSAIDs; STEROIDS FOR ABD PAIN risk GI bleed & ileoilial intuss
ITP: more or less common than HSP?	LESS COMMON (5:100k compared to 10:100k)
ITP: –age? –M or F?	2–5yo (younger than HSP) M=F
What dz: non–specific viral infxn ––> anti–plt Abs that bind plt surface ––> liver & spleen destroy plts	ITP
HSP or ITP: YOUNGER	ITP (2–5yo) (contrast HSP 4–6)
HSP or ITP: M > F	HSP
HSP or ITP: M = F	ITP
HSP or ITP: IgA deposits	HSP (contrast ITP: anti–plt Abs)
HSP or ITP: Anti–platelet Abs	ITP (contrast HSP: IgA deposits)
HSP or ITP: Usually preceded by viral infxn	BOTH HSP: viral/bact URI ITP: non–specific viral infxn
ITP: presents with petech/bruising and what OTHER sxs?	NONE (may see epistax, ICH)
ITP: –hepatosplenomeg? –arthralgia?	NO
ITP is intracranial hemorrhage common?	NO – 0.5%
ITP: plts <___?	<20k
ITP: do most pts develop significant bleed?	NO
What dz: viral infxn ––> PETECHIA, BRUISING ––> normal WBC, platelets <20k	ITP
ITP: how tx? (3)	Steroid IVIg Rhogham (anti–D)
Leukemia: see change in platelets?	Decrease (<100k) (BM infiltrate ––> see other cytopenias)
What dz: Petech/purp + bone pain + hepatosplenomeg	Leukemia
To percuss liver: Child in what position?	Supine w/knees bent
Normal liver size: –neonate –child	Neonate: 3.5cm Child: 2.0cm
Leukemia: see hepatomeg?	YES – due infiltration
Glycogen storage dz: see small or large liver?	Hepatomeg
Spleen palpable in what %: –neonates –children –adols	Neonate: 33% Child: 10% Adol: 2%
Spleen: what size is ABNORMAL?	>2cm
See splenomegaly?: Endocarditis	Yes
See splenomegaly?: SLE	Yes
Which storage disease: See splenomegaly	GAUCHER
LNs: abn if what size?	>2cm
Palpable LNs are considered NORMAL in what 3 areas?	Cervical Ax Inguinal ––> anywhere else is abn
Shaken Baby Syndrome: –what % die? what % poor neuro outcome? –account what % child abuse death?	25% die, 40% poor neuro outcome 10% child abuse death
Shaken Baby Syndrome: Pinpoint OR dilated pupils?	DILATED
Shaken Baby Syndrome: Stiff or limp?	STIFF
Shaken Baby Syndrome: Higher mortality if <1yo or >1yo?	<1yo
Shaken Baby Syndrome: What TYPE of brain bleed?	Subdural
Subdural bleed in neonate: 2 main etios?	1. Shaken baby 2. Vacuum NOT szs
Increased ICP in neonate: how affect breathing?	See APNEA
Bacterial mening in neonate: what % have hearing loss?	0.2
Arrythmia: common to see apnea?	NO See: decreased feed, irritable, lethargic
Suspect increased ICP if: SLOW or RAPID rr?	SLOW
R/o subdural bleed: what imaging 1st?	CT ––> serial CT to monitor
Which brain imaging best for: Shearing injury	MRI
Shaken Baby Syndrome: –Administer what ppx meds? –what imaging (aside from brain)?	Anti–epileptics Skeletal survey
Apnea: definition (2)	1. No breathe >20s 2. No breath (<20s) plus brady (<100) or pallor–cyanosis
#1 problem in prematures	Apnea
What type of shock: WARM EXTREMS	Septic
Can viral infection lead to septic shock?	Yes (via toxin production)
What type of shock: ADEQUATE UOP	Septic
What type of shock: Bounding pulse	Septic
Septic shock: How tx? (2 immed management steps)	Boluses ––> Vasopressors (E/NE/DA)
Leads to what type of shock?: Cardiomyopathy	Cardiogenic
Leads to what type of shock?: Tamponade	Cardiogenic
Cardiogenic shock: Cool or warm extrems?	Cool
Cardiogenic shock: how affect UOP?	Decrease UOP
Leads to what type of shock?: Anaphylaxis	Distributive shock
Leads to what type of shock?: SIRS	Distributive shock
Hypoglycemia: see fever?	No
Encephalitis: how affect resp rate?	NORMAL ––– tachypnea uncommon! (contrast meningitis)
PNA in infant: expect mental status change?	No
Toxic shock syndrome: how does rash appear?	Sunburn–like sandpaper
What dz: Pastia's Sign	Scarlet Fever (linear petechia in body folds)
Scarlet Fever: see desquam?	Yes (5d after rash)
Name for: Scarlet Fever ––> linear petechia in body folds	Pastia's sign

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