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1407 Cards in this Set
- Front
- Back
- 3rd side (hint)
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 |
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Intrauterine factors affecting fetal growth: Placental abnormalities? |
Placenta previa, placental abruptions or abnormal umbilical vessel insertions may lead to suboptimal fetal growth.
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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
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IUGR: poor wt gain in which TM is a risk factor? |
TM3
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IUGR: due to fetal abns? |
Possible; can see with chromo abns, metabolic dz, congen infxn
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What is safe amt of EtOH in preg? |
NO SAFE AMT
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Smoking ––> what facial abns? |
none
just low bw |
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How does cocaine/stimulant affect birth weight? (mxn) |
Vasocon ––> placental insuff ––> low bw
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What drug: s/e fetal hydantoin syndrome |
Phenytoin
(see in 30% exposed infants) |
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Phenytoin: safe in preg? safe in breastfeed? |
S/E Fetal Hydantoin Synd (30% exposed fetuses)
SAFE IN BREAST FEED |
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Suspect what etiology: Neonate with: hypoplastic nails & distal phalanges, cardiac defects, cranio deforms, IUGR, M.R. |
Phenytoin ––> fetal hydantoin syndrome
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Higher risk in young or old moms: –GHTN –Preeclampsia |
ADOLESCENT moms
––> low birth wt neonates |
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All states screen for these two inborn errors of metabolism |
PKU, Hypothyroidism
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Absolute contraindications to breastfeeding? |
Maternal HIV, active maternal drug abuse, infants with galactosemia
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Exclusive breastfeeding recommend for how long? |
First 6 mo of life, then breastfeeding plus complementary foods until infant at least 12mo
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Breastfeeding lowers rates of what? |
Diarrhea, acute and recurrent otitis media, UTIs
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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.) |
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Infants born to adolescent mothers are at greater risk for lower birth weight bc… |
pregnancy-induced hypertension
preeclampsia vertically acquired sexually transmitted diseases |
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APGAR stands for… |
A = Appearance (skin color)
P = Pulse (heart rate) G = Grimace (facial expression) A = Activity (neuromuscular tone) R = Respirations (respiratory effort) |
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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 |
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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 |
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Topical eye antibiotics for newborns decreases risk for transmission of… |
Gonococcal conjunctivitis (NOT chlamydia)
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Which measure: Most sensitive indicator of growth abnormalities |
growth VELOCITY
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EBV: what % 35–40yo infected? |
0.95
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EBV: infection in adol ––> what % develop mononucleosis? |
35–50%
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EBV: –fever? –LAD? –sore throat? –how long is incubation? |
fever + sore throat + swollen LNs
Incubates 4–6w |
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HIV+ mother ––> what % risk infection (if untreated)? |
25–30%
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Maternal HIV: increase risk transmission if: –SVD or C/S? –ROM > ___h –what gestation? |
SVD
ROM >4h <37w |
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Mother w/unknown HIV risk ––> would you perform newborn screen? |
YES
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Neonatal HIV: see splenomeg? |
possibly
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TORCH: what stand for? |
Toxo
Other: HIV, HBV, parvo, syph Rub CMV HSV–2 |
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Congenital toxo: how screen: –0–6mo –>1yo |
0–6mo: infant IgM or IgA
>1yo: IgG |
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Does presence of maternal HBcAb predict risk transmit? HBsAg? |
HBcAb: no (could indic past infnx)
HBsAg: yes |
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Next step: presence of HBsAg in mother ––> ? |
Give mother AND neonate:
1. HBV vaccine 2. HBIg |
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Detect via what test: Maternal HIV |
PCR
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Congenital rubella: how test: –0–6mo –>1yo |
0–6mo: IgM
1yo: IgG |
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Congenital CMV: how detect in neonate? next management step? |
URINE CULTURE in weeks 0–3
(if pos ––> routine hearing test) |
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Which congenital infection: if positive ––> routine hearing test |
CMV
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CMV: –hearing loss abrupt or progressive? –occurs birth or 1yo? |
Progressive
Can occur birth OR up to 1yo (continuously monitor) |
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What dz: Infant w/microcephaly, intracranial Ca2+, lissencephaly, rash |
congenital CMV
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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 |
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congenital CMV: how tx neonate? |
Antivirals ONLY IF BABY IS IMMUNOCOMPROMISED
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Routine neonate meds: –how admin vitamin K? –Erythro eye drops covers which STD? |
IM vitamin K
Gonococcus |
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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. |
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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. |
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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. |
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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). |
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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
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Autism screen recommended at these two ages |
18mo, 2 years
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How long s/p birth: –Colustrum available –Milk available |
Colustrum: immed
Milk: w/in 40h |
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Infant WCC: What s/sx is most sensitive indicator of NUTRITIONAL status? |
WEIGHT
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S/p birth: Neonate feeds how many times in first 24h? |
Immed ––> 8–12x
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What age: Introduce free H2O? |
4–6mo
(once taking solid foods) |
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First days of life: does colustrum meet nutritional reqs? |
YES
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0–6mo: Does soy formula have enough protein? |
yes
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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 |
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Calorie reqs for infant that is: –term –preterm –very low bw |
Term: 100–120 cal/kg/d
Preterm: 115–130 Very low bw: 150 |
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Do breast–fed infants req vitamin D? Formula fed? |
ALL infants req supp vitamin D ~400 units/day
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ALL infants (breast & formula) req what supplement? |
Vitamin D
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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) |
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What age: Introduce solid foods (rice cereal) |
4–6mos
(IRON–fortified solids) (many premies NOT ready for solids at 4mos) |
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What age: Eat STRAINED foods (pasta, toast, banana) |
9mos
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9mo: req how many calories/day? What % from milk/formula? |
100 cal/kg/d
75% breastmilk/formula |
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What age: Infant feeds themselves |
9mos
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What age: Introduce toast, pasta, banana |
9mo
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What age: Introduce MEAT |
9mo
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Infant: how often introduce 1 new food? |
q5–7 days start 1
(ID allergies) |
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Infant: when introduce hot dog? |
NEVER – choke
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Term infant: Gains how much wt per day? |
20–30 g/day
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4mo: weights ____x birth weight |
2x bw
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What age: Weigh 2x birth weight |
4mo
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What age: Weight 3x birth weight |
12mo
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1yo: weighs ___x birth weight |
3x
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<1yo: –# wet diapers per day –# stools per day |
6+ wet
6–8 stools |
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What age: 2x birth LENGTH |
4 years
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4yrs: ___x birth length |
2x length
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Red reflex: hold opthalmoscope how far from infant? |
10 inches
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Red reflex: what 1st see? |
at BIRTH
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Red reflex present or absent?: Cataracts |
Absent
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Red reflex present or absent?: Glaucoma |
Absent
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Red reflex present or absent?: Retinoblastoma |
Absent
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Red reflex present or absent?: Chorioretinitis |
Absent
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4 major areas of developmental milestones |
Gross Motor
Fine motor Language Social/Adaptive |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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Vaccines: 2, 4, 6mo |
PHHRID
PCV Hib, Hep B Rotavirus IPV DTap |
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Vaccines: 1 year |
HaMV
Hep A MMR Varicella |
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Vaccines: 15mo |
DIP
DTaP IPV PCV |
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Vaccines: 4yo |
DM 4 = DMIV
DTaP MMR IPV Varicella |
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Vaccines: 11yo |
Tdap
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Why is use of acetaminophen after a vaccine a bad idea? |
Acetaminophen can cause lower antibody response for sme immunizations
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What is youngest age you administer INFLUENZA? |
6mo
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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
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Immunization S/E: fussy + fever –how long last? –need to see doc? |
Commonly last 24h
If >24 ––> see doc |
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What age: Baby sleeps through night |
4–6mo
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How position in car: <1yo |
carseat, middle back seat, face back
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How position in car: <10kg |
carseat, middle back seat, face back
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How position in car: 1–4yo |
Carseat, backseat, face forward
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How position in car: 4–8yo |
Booster, back, forward
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How position in car: 8–12yo |
Backseat, face forward
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SURVEY or SCREEN?: Bright futures |
Survey
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SURVEY or SCREEN?: PEDS test |
Screen
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SURVEY or SCREEN?: M–CHAT |
Screen
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What is name for peds SURVEY most commonly used? |
Bright Futures
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What age: Laughs, smiles |
2mo
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What age: Sits unsupported |
6mo
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What age: Look for dropped item |
6mo
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What age: Stranger RECOG |
6mo
(contrast anxiety– 9mo) |
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What age: Stand w/support |
9mo
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What age: mama, dada (nonspecific) |
9mo
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What age: Patty–cake |
9mo
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What age: STRANGER ANX |
9mo
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What age: Stands alone |
1yo
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What age: Mama, Dada – SPECIFIC |
1yo
(contrast non–specific – 9mo) |
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Infant screening: do low measures of social/cog & language ––> predict intellectual delays? |
YES
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What age: Tricycle |
3yo
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What age: CIRCLE |
3yo
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What age: Cross |
3yo
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What age: Knows name, age, sex |
3yo
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3yo: can draw what shape? |
Circle, cross
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What age: Knows 2 actions, 1 color |
3yo
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3yo: knows how many actions? colors? |
2 actions
1 color |
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What age: Toilet training |
3yo
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What age: Able to eat at table |
3yo
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3yo nutrition: normal to prefer BLAND foods? |
yes
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What age: 1st dentist visit |
3yo
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What age: d/c bottle |
1yo
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Do developmental surveys alone adequately identify developmental delays? |
No
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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 |
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What age: Dresses self, feeds self |
3yo
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What age: Knows gender and age, friendly to other children, plays with toys/engage in fantasy play |
4yo
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What age: • Listens and attends • Can tell difference between real and make-believe • Shows sympathy/concern for others |
5yo
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What age: • Speaks in 2- to 3-word sentences • 75% understandable |
3yo
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What age: • States first and last name • Sings a song • Most speech clearly understandable |
4yo
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What age: • Articulates well • Tells a simple story using full sentences • Uses appropriate tenses and pronouns • Counts to 10 • Follows simple directions |
5yo
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What age: • Knows name and use of cup, ball, spoon, crayon |
3yo
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What age: • Names colors • Aware of gender • Plays board games • Draws person with 3 parts • Copies a cross |
4yo
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What age: • Draws a person with > 6 body parts • Prints some letters and numbers • Copies squares and triangles |
5yo
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What age: • Builds tower of 6-8 cubes • Throws a ball overhand • Rides a tricycle • Copies a circle |
3yo
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What age: • Hops on one foot • Balances for 2 seconds • Pours, cuts, and mashes own food • Brushes teeth |
4yo
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What age: • Balances on one foot • Hops and skips • Ties a knot • Has mature pencil grasp • Undresses/dresses with minimal assistance |
5yo
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What test: Parents answer illustrated 30–item question at designated intervals |
Ages & Stages Questionarre (ASQ)
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What test: 5 key areas (commun, gross & fine motor, prob–solv, personal/social) |
Ages & Stages (ASQ)
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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 |
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Low or high sens & spec: –ASQ –PEDS test |
Both high spec & sens
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What test: parent answers Y/N/sometimes ––> color–coded score ––> user guide to assess risk |
ASQ
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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 |
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What test: 10 questions ––> use to screen development OR assess parent's concerns |
Parent's Eval of Developmental Status (PEDS test)
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What test: used in: –0–5yo –0–6yo –0–8yo |
0–5: ASQ
0–6: Denver II 0–8: PEDS |
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What test: Reqs direct observation & parent report |
Denver II
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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 |
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What test: TEACHES developmental milestones |
Denver II
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What test: Reqs child cooperation ––> time–consuming |
Denver II
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Premature birth: CORRECTED AGE = |
Chronologic age – days/mos prematurity
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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 |
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DDX ASYMPTOMATIC palpable abdominal mass in 2mo? |
Hepatic Neoplasm
Hydronephrosis Neuroblastoma Teratoma Wilms' tumor (nephroblastoma) |
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DDX SYMPTOMATIC palpable abdominal mass in 2mo? |
Appendiceal abscess
CHF (hepatomegaly) Constipation Hepatic abscess |
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Neuroblastoma in abdomen <1yo: –sympto? jaundice? –how affect G&D? |
Asympto, no jaundice
May see normal G&D |
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What dz: Abd CT: heterogeneous, cystic mass with calcifications |
Neuroblastoma
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Neuroblastoma in abdomen <1yo: 2 sites of mets |
Chest LNs
Posterior mediastinum |
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What dz: Small round BLUE CELLS |
Neuroblastoma
(e.g. abdominal) |
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Neuroblastoma in abdomen <1yo: How appear tumor cells (histo) |
small round blue cells
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What dz: Bone marrow ROSETTES |
Neuroblastoma
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What dz: Tumor cells w/dense, hyperchromic nuclei |
Neuroblastoma
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Neuroblastoma in abdomen <1yo: How affect CBC? |
BM infiltrate ––> ANEMIA, other cytopenia
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Neuroblastoma in abdomen <1yo: In/decrease urine HVA:VMA? |
INCREASE
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What dz: Abdominal mass in infant + increased HVA/VMA |
Neuroblastoma
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Wilms tumor: see LAD? |
NO
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Abdominal neuroblastoma: CT appears homo/heterogeneous? cysts? |
HETERO
CYSTS (hemorrh, necrosis) |
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Which has more hemorrhage & necrosis: Wilms tumor or neuroblastoma? |
Neuroblastoma
(appears more cystic on CT) |
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What dz: Abd mass + heterogenous mass (CT) + PSEUDOCAPSULE |
Wilms tumor
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Wilms tumor: CT shows demarcation b/w tumor & parenchyma? |
YES
=pseudocapsule |
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Wilms tumor: where mets? |
PULM (see on CXR)
(contrast neuroblastoma – mets to chest LNs & post mediastinum) |
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Wilms tumor: req BM aspiration? |
NO – only if:
1. pain 2. unfavorable tumor histo |
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Wilm's tumor: affect UA? |
Yes – hematuria
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Abdominal TERATOMA in infant: common or rare? |
RARE
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Abdominal teratoma: see jaundice? pallor? |
No neither
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Hepatic tumor in infant: common or rare? see jaundice? affect G&D? |
RARE
jaundice decreased G&D |
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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. |
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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.
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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. |
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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. |
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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.
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Eczema / Atopic dermatitis: 2/2 what TWO immune mxns? |
1. Increased IgE
2. Dysregulated Ab production (encoded by DIFFERENT gene sets) |
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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 |
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DDX for Eczema? |
Psoriasis: rare in children
Seborrhea: Cradle cap in infants |
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More more than how many oz of juice per day? |
4-6oz
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Enlarged thyroid common or rare in child? |
RARE
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Enlarged Lymph Nodess: –common or rare in toddler? –non/tender? –shotty located in what areas? |
Common
NT Shotty in ANT & POST cervical |
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Murmur in toddler: –most non/fxnl? |
FUNCTIONAL
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NEW murmur: common due to congen heart disease? |
No
––rarely 2/2 congen |
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Most common abdominal mass in children? |
Stool
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In–toeing in toddler: commonly due to what anatomic variant? |
Tibial torsion
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Tibial torsion in toddler: leads to what type of gait? |
IN–TOEING
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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 |
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MCC nonspecific vulval erythema in female toddlers? |
Poor hygeiene once they are toilet training and caring for themselves in bathroom
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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 |
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Anemia in 3yo: #1 etio |
Iron–deficiency 2/2 malnutrition
Less common causes: chronic GI blood loss due to food allergies, gluten enteropathy |
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Anemia in 3yo: Is anemia itself a good predictor of Fe2+ deficiency? |
NO –– poor predictor of iron def in diet
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HIV in infant: expect anemia? |
YES (ACD)
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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 |
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What dz: Microcytic anemia with decreased RDW |
thalasemmia, sickle cell dz
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Micro/normo/macro anemia: –SCD –Thal |
Both MICRO
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Mild (>9) or severe (<9) anemia: Aplastic anemia |
severe
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Mild (>9) or severe (<9) anemia: Folate deficiency |
severe
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Mild (>9) or severe (<9) anemia: B6 deficiency |
Severe
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What 3 nutritional defs can cause anemia? |
Iron
Folate B6 |
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3yo w/IDA: req iron supplement OR can just encourage iron–rich foods? |
Give Fe2+
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INITIAL labs in anemia w/u: –retic? –smear? |
YES
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INITIAL labs in anemia w/u: –stool blood? –UA? |
YES
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Iron–def anemia: –micro/macro? –hypo/hyperchromic? –DEC/INCREASED retics? |
Micro, hypo
DECREASED RETICS |
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Hemophilia A or B: Decreased VIII |
A
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Hemophilia A or B: Decreased IX |
B
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Hemophilia A: what def? |
Decreased VIII (8)
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Hemophilia B: what def? |
Decreased IX (9)
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Hemophilia: how affect: –PTT –Bleed time |
PTT: prolonged
Bleed time: normal |
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What dz: Prolonged PTT, normal bleed time |
Hemophilia
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How inherit: Hemophilia |
X– RECESSIVE
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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. |
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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. |
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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
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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
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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.
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3yo: limit how many meals & how many snacks? |
3 meals, 2 snacks
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How determine: WEIGHT AGE |
Age at which wt plots @ 50%
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BMI = |
Kg/m2
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BMI: what # and %tile: –overweight –obese |
Over: 25–30 (85–95%)
Obese: >30 (>95%) |
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Predispose to UNDER or OVERweight: Bardet–Biedl syndrome |
Over
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Predispose to UNDER or OVERweight: Cohen syndrome |
Over
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Does high birthweight correl w/childhood obesity? |
YES
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What % of 6–19yo are obest? |
0.15
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Childhood obese: assoc w/SES? |
Yes –– low SES
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What % will become obese adults?: –obese 4yo –obese adolescent |
4yo ––> 20% obese adults
adol ––> 80% obese adults |
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What is increased risk that child will be obese: –1 obese parent –2 obese parents |
1: 3x
2: 10x |
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Under 3yo: which is stronger predictor of obesity in adulthood: Child's current wt OR parental obesity |
Parental obesity
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Early adolescence: normal to see dec/increase insulin sensitivity? |
Adol ––> DECREASE insulin sensitivity (i.e. normal to see transient insulin resistance) ––> increase wt gain
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What fraction of obese children are hypertensive? |
1/3 of children with BMI>95th %ile
9x more frequent in overweight kids |
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Obesity: assoc with restrictive lung disease? reactive? |
Restrictive (inc Obstructive Sleep Apnea, Pickwickian Syndrome)
NOT assoc w/reactive airway disease |
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Obesity: GI associations? |
Non-alcoholic steatohepatitis
Gallbladder disease |
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Obesity: assoc w/Blount disease? |
YES
(outward bowing of tibia) |
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What dz: Widening of physis (hip x–ray) |
SCFE
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SCFE: wide or narrow physis? |
WIDE
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SCFE: displace what 2 components of femur? |
HEAD & NECK (thru physeal plate)
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What dz: obese kid w/delayed sex maturation & antalgic gait |
SCFE
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SCFE: see limited INT or EXT rotation of hip? |
limited INTERNAL rotation
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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 |
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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 |
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Obese child: –limit TV hrs? –amt exercise |
TV <2h
Exercise: 60min every day |
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Obesity + low HDL + high triglycerides = ? |
Metabolic Syndrome
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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 |
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A2DM: Up to 1/3 of children with Type 2 DM are accidentally diagnosed. How? |
UA --> ketones in urine
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Childhood DM: inc/decrease appetite? |
INCREASE (polyphagia)
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What # to dx DM: –Random BG –Fasting –2h OGT ––Which method preferred to dx DM? |
Random: >200
Fast: >120 2h OGT: >200 FASTING PREFERRED |
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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 |
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How define NORMAL BP in child? |
Both SBP & DBP <90% (age/gender/ht/wt)
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What age: Start routine BP check |
3yo
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Name for: SBP & DBP: –90–95% –95–99% –>99% |
90–95%: pre–hypertension
95–99%: stage I HTN >99: stage II |
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What % SBP & DBP: Pre–hypertension |
90–95%
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What % SBP & DBP: Stage I HTN |
95–99%
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What % SBP & DBP: Stage II HTN |
>99%
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Increased BP in >6yo: mcc due to 1' or 2' HTN? Important correlate? |
PRIMARY, assoc. with obesity
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What dz: Young child with HTN + no family hx HTN |
Coarctation of Aorta, renal parenchymal disease
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Early menarche vs. Delayed puberty -- which assoc with BMI > 85th %ile? |
Early Menarche
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Childhood HTN: damages which heart chamber? |
LVH
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ADHD: sxs for how long? # settings? |
6+ mos and before 7yo
2+ settings |
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ADHD: req how many sxs (inattn or hyper)? |
6+
(either type) |
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How distinguish inattention ADHD from sleep disorder (e.g. Obstructive Sleep Apnea)? |
Sleep: decreased sleep & tired
ADHD: poor sleep but NOT over–tired |
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MDD in child: high rate of converting to what psych condition? |
MANIA / Bipolar Disorder (looks like hyperactivity so can mimic/accompany ADHD)
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ADHD: assoc w/oppositional defiance disorder? conduct disorder? |
BOTH
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ADHD: how tx? (1 drug; know dosing) |
Sustained–release methylphenidate (concerta) 18mg po bid
BIDBIDBID |
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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. |
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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). |
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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. |
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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.
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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. |
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Pedigree: try to get how many generations? |
3rd
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How inherit: Marfan |
AD
(DOM!) |
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How inherit: neurofibromatosis |
AD
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How inherit: Duchenne's Musc Dys, Hemophilia |
XR
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How inherit: MELAS |
Mitochondrial (inheritedfrom mother --> all children can be affected. Affected males will NOT have affected children)
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How inherit: CF |
AR
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How inherit: Tay–Sachs |
AR
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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 |
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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) |
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What Tanner Stage: Testes <1.5 mL |
1
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What Tanner Stage: No pubes |
1
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What Tanner Stage: Testes 1.6 – 6 mL |
2
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What Tanner Stage: Red, thin scrotum |
2
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What Tanner Stage: Thin pubes at base of penis |
2
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What Tanner Stage: Testes 6–12 mL |
3
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What Tanner Stage: Curly, coarse hair |
3
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What Tanner Stage: Testes 12–20 |
4
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What Tanner Stage: Darken & increase size of scrotum |
4
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What Tanner Stage: Adult pubes but absent on thighs |
4
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What Tanner Stage: >20 ml testes |
5
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What Tanner Stage: Pubes on medial thighs |
5
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Delivering bad news: is it OK to TOUCH pt? |
YES
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Teen interview: should you set up expectation for interview at beginning? |
Yes
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Teen: start with specific OR open–ended questions? |
SPECIFIC
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Teen interview: if parent refuses to leave ––> should you advocate for adolescent privacy? |
Yes
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T/F offer HIV test to ALL sexually–active >13yo |
TRUE
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Normal range puberty: –F –M |
F: 8–13yo
M: 10–15yo |
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Tanner staging: assess what 2 features (M, F)? |
M: pubes, testes
F: pubes, breasts |
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Name for: Measure of BODY COMPOSITION |
anthropometry
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Cause of anemia in teenage female? |
heavy periods
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Bleeding disorder suspected in teenage female with fatigue? |
vWD
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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)
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Other than bleeding disorder (vWD), another cause of fatigue in teenage female? |
Hypothyroidism
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Symptoms of hypothyroidism? |
cold skin, slowness, fatigue, prefer hot weather to cold, doing poorly in school, menorrhagia, shorter menstrual cycles
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How inherit: vWD |
AD
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What dz: –prolonged PTT, normal bleed time –prolonged bleed time, normal PT |
HemoPhilia: prolonged PTT, normal bleed time
vWD: prolonged bleeD time, normal PT |
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vWD: how inherit –Type I –II –III |
I&II: AD
III: AR |
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vWD: what is defect in: –type I –II –III |
I: decreased vWF (mild)
II: QUAL defect III: undetectable vWF (severe) |
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vWD: which TYPE? Decreased vWF; MILDEST |
I
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vWD: which TYPE? Most common (70%) |
I
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vWD: which TYPE? inherited AR |
III
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vWD: which TYPE? QUAL defect |
II
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vWD: which TYPE? Undetectable vWF |
III
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vWD: which TYPE? Most severe |
III (undetectable vWF)
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vWD: how tx? |
Intranasal OR IV desmo
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What dz?: Tx w/intranasal or IV desmopressin |
vWD
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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. |
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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. |
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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. |
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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. |
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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. |
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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 |
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DDX for chest pain |
Precordial catch syndrome
Musculoskeletal / costochondritis GI/GERD Cardiac Respiratory/asthma |
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#1 sudden death adol athlete |
Hypertrophic Obstructive Cardiomyopathy (HCOM)
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Hypertrophic Obstructive Cardiomyopathy (HCOM): –p/w what sx? –what % have abn EKG? |
SYNCOPE
90% abn EKG |
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Child w/chest pain: higher suspicion of CARDIAC vs chest wall pain etiology if: present at rest OR exercise only? |
Exercise only
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Chest pain due myocardial ischemia: –sharp or dull? –how long last? |
Dull pressure
10–20 mins |
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What dz: Sharp/stabbing chest pain REPRODUCIBLE w/direct sternal pressure |
Costochondritis
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Costochondritis: how long does pain last? |
few seconds of stabbing over hrs–days
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Costochondritis: chest pain assoc w/exercise? |
NO – sporadic
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What is dz: Chest pain worse with deep inspiration |
Costochondritis
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Costochondritis: worse with insp or exp? |
Deep insp
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Which more common: Precordial catch OR costochondritis |
Precordial catch
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#1 chest pain in child |
Precordial catch
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Precordial catch: assoc w/exercise? |
No
(occurs equally at rest or exercise) |
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Precordial catch: –diffuse or well–localized? where most common? –sharp or dull? |
sharp, well–localized at LOWER STERNAL BORDER
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Precordial catch: how long pain last? |
secs–mins
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Precordial catch: worse w/insp or exp? |
Deep insp
(same as costochondritis) |
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What dz: Chest pain that pt can BREAK with forced deep insp |
Precordial catch
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Costochondritis or Precordial catch? Pain due to inflammation, usually follows a recent viral infection, muscle strain, trauma, or overuse |
Costochondritis
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Name for: Inadeq cerebral BF ––> transient LOC & loss of postural tone |
Syncope
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Syncope: underlying mxn? |
Decreased cerebral BF
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3 general etios of syncope in child |
1. Neurocardiogenic (vasovagal; #1)
2. Neuropsych (szs, orthostatic, drugs) 3. Cardiac (arryth, structure defect) |
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Syncope 2/2 orthostatic hypotension: classify as NEUROPSYCHIATRIC or CARDIOGENIC? |
Neuropsychiatric
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What drug class: S/E prolonged QT ––> neuropsychiatric syncope |
Antihistamines
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Antihistamines: S/E what EKG change? |
Prolonged QT
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Difference b/w 1' and 2' cardiac syncope |
1': structural defect ––> obstruct ventricular outflow
2': ventricle DYSFXN or ARRYTH |
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3 types of arryths that can cause syncope |
1. SVT
2. VT 3. Heart block (2/2 Lyme) |
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Syncope in child: EKG which pts? |
ALL
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Syncope in child: which is more serious: Pallor OR warm/flushed skin |
WARM/FLUSHED
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Syncope during exercise: mandatory refer to cardio? |
YES
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Are murmurs COMMON in healthy adols? |
Yes
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Teen physical: Palp which 2 pulses? |
Femoral
Radial ––> assess Ao coarct |
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HCM: murmur louder supine OR standing? |
STANDING
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Murmur: evaluate if louder than ___ (what grade?) |
III/IV
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Teen physical: How long should orthopedic exam take? |
2min
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Teen physical: Require chaperone for GU? |
always
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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 |
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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 |
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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 |
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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. |
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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. |
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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! |
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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. |
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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. |
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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 |
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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) |
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Which is more predictive of LT neuro outcomes: Umbilical artery blood sample OR APGAR |
Umb art
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Perinatal asphyxia: detect via sampling which blood vessel in cord? |
Umb ARTERY ––> detect hypoxia, acidosis
(NOT vein) |
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GDM: predispose neonate to: –hypo or hypergly? –hypo or hyperCa? |
Hypogly (due increased insulin)
HypoCa2+ |
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GDM: is neonate at increased risk of resp distress? |
YES
|
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Fetal glucose: normally what fraction of maternal glucose? |
2/3 maternal glucose
(glucose crosses placenta) |
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GOAL BLOOD GLUCOSE IN NEONATE |
41–50
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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 |
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Persistent pulmonary HTN of newborn: –underlying etio –where does blood divert? |
Due elevated pulm vasc R
Blood diverts through ductus arteriosus & PFO (bypasses lungs) |
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Persistent pulmonary HTN of neonate: presents with tachy/bradycardia? |
Tachy
(also tachypnea) |
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Cyanotic newborn: order an O2 challenge test? |
YES --> cardiac vs. pulm etiology
|
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Acrocyanosis at birth: –usu resolves after how long? –when start to suspect congenital HD? |
Usu resolves 4–5h
After 8h warming ––> suspect congen HD |
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#1 etio respiratory distress in preterm |
Resp Distress Syndrome (RDS)
aka Hyaline Membrane Dz |
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Respiratory Distress Syndrome in neonate: underlying etio |
Surfactant deficiency
|
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Name for: Neonatal dz caused by surfactant deficiency |
Respiratory distress syndrome
|
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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 |
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Respiratory Distress Syndrome in neonate: If mother has GDM ––> may see RDS in infant up until how many weeks gest? |
37
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Neonatal with resp distress: which is more common if healthy mother and gest >34w: RDS or transient tachypnea of newborn |
TTN
|
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How distinguish (what test): RDS vs. TTN |
CXR
RDS: air bronchograms, ground glass |
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What dz: Newborn with resp distress & CXR w/bronchograms & ground glass |
RDS
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Transient tachypnea of newborn: More common term or preterm? |
TERM !!!!
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Transient tachypnea of newborn: Underlying etio |
Delayed fluid clearance
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Transient tachypnea of newborn: Early or late onset? Mild or severe distress? |
Early onset, mild distress
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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) |
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What dz: Neonate w/resp distress & CXR w/perihilar streaking, coarse densities and WET LOOKING lungs |
TTN
(contrast RDS: bronchograms, ground glass) |
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TTN or RDS: Male |
BOTH
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TTN or RDS: Perihilar streaking |
TTN
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TTN or RDS: Fluffy densities |
TTN
(contrast RDS: ground glass) |
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TTN or RDS: Lateral view shows fluid in pleural space, fissures |
TTN
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TTN or RDS: WET LOOKING LUNGS |
TTN
|
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Pneumothorax: More common in premie? |
YES
|
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Neonatal sepsis/PNA: assoc w/PROM? |
Yes – may have subtle early findings like poor feed, lethargy
|
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Meconium aspiration: occurs when in birth process? |
In utero
OR 1st breath |
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TTN: expect to resolve after how long? |
12h
|
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If suspect TTN but respiratory sxs do not improve, suspect WHAT? Next steps? |
Suspect Pneumonia
Order repeat CXR, Start antibiotics |
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|
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
|
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Which is better predictor of neonatal death: 1– or 5–min apgar |
5–min
(although best is umb art sample) |
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|
What birthweight #s: Extremely low bw |
<1,000 g
(contrast very low: 1k – 1,499) |
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What birthweight #s: Very low bw |
1,000–1,499
|
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What birthweight #s: Low bw |
1,500 – 2,499
(contrast very low: 1,000–1,499) |
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|
What birthweight #s: NORMAL |
2,500 – 4,000
|
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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) |
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Cephalohematoma: 2/2 what device? |
VACUUM
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If baby is LGA ––> risk hypo or hypergly? |
HYPO
(same if baby is SGA ––– inadeq glycogen stores) |
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|
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) |
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|
SGA neonate: expect pale or ruddy? |
RUDDY ––– due polycythemia ––> increased viscosity
|
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Premature infant: do you need to establish breast–feeding before discharge? |
YES
(risk hypothermia, decreased glycogen stores) |
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|
Newborn: Is 1st phys exam (at birth) a good indication of successful transition to extrauterine? |
YES
|
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Newborn: 1st breath ––> where does fluid in lungs go? |
Squeezed out (cxns, air) ––> absorbed by PULMONARY LYMPHOCYTES
|
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0–1h life: normal V/S: –pulse –rr |
p 160–180
rr 60–80 |
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2h life: normal V/S: –pulse –rr |
p 120–160
rr 40–60 |
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2h neonate: suspect resp distress if RR > ____ |
rr > 60
Also: use of accessory muscles (nasal flaring, intercostal retractions, grunting), hypoxia, hypercapnia |
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Neonate: Use glucometer to confirm hypogly? |
NO – use to SCREEN
(NOT confirm) |
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Neonate glucometer read: If neonate BG <40 –––> what is next step? |
Meas serum BG (to confirm neonatal hypogly)
START TX WHILE WAITING |
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|
Neonate glucometer: Start tx if neonatal BG < ___ |
<40
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If neonate with RDS ––> order what 3 tests? |
1. CBC w/diff
, CSF cx 2. Blood cx 3. LP --> r/o Sepsis |
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Tx hypoglycemic neonate if: –symptomatic and BG <___ –asympto and BG <___ |
sympto & <45
asympto & <35 |
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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 |
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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. |
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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. |
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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. |
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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. |
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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. |
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Jaundice: accum bili in what skin layer? |
Epiderm
|
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Jaundice: Occurs what % newborns? |
0.6
|
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How does bilirubin travel in blood? |
Binds ALBUMIN
|
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Bilirubin: Transported by albumin to what site? |
LIVER
|
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Bilirubin: Conjugated in liver by WHAT ENZYME? |
UDPGT
|
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UDPGT: fxn? |
Conjugates bilirubin (transported from blood to liver) with glucoronide
|
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Bilirubin: Conjugated to WHAT MOLECULE in liver? |
glucoronide (via UDPGT)
|
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Conjugated bilirubin is excreted into bile in WHAT FORM? |
Stercobilirubin
|
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Unconj (indirect) or Conj (direct): Physiologic jaundice |
Unconj
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Unconj (indirect) or Conj (direct): Breast milk jaundice |
UNconj
|
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Unconj (indirect) or Conj (direct): Breast feed jaundice |
Unconj
|
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Unconj (indirect) or Conj (direct): Direct Coombs jaundice |
Unconj
|
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Unconj (indirect) or Conj (direct): Jaundice 2/2 spherocytosis |
Unconj
|
|
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Unconj (indirect) or Conj (direct): PK deficiency |
Unconj
|
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Unconj (indirect) or Conj (direct): Jaundice due G6PD |
Unconj
|
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Unconj (indirect) or Conj (direct): Jaundice 2/2 cephalohematoma |
Unconj
|
|
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Unconj (indirect) or Conj (direct): Jaundice 2/2 bruising |
Unconj
|
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Unconj (indirect) or Conj (direct): Jaundice 2/2 swallowed blood |
UNconj
|
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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) |
|
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Unconj (indirect) or Conj (direct): Jaundice 2/2 neonatal asphyxia |
Conj
(due liver ischemia) |
|
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Unconj (indirect) or Conj (direct): Jaundice 2/2 sepsis |
Conj
(liver isch) |
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Unconj (indirect) or Conj (direct): Jaundice 2/2 congenital metabolic toxins |
Cong
(liver isch) |
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Unconj (indirect) or Conj (direct): Jaundice 2/2 biliary atresia, intestinal malrotation |
COng
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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 |
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Physiologic jaundice: what 2 mxns? |
Lack gut flora & increased activity beta–glucoronidase ––> convert bili to unconj and reabsorb
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Leads to what dz: Neonate lacks gut flora & has increased beta–glucoronidase ––> converts bili to unconj form ––> reabsorbs |
Physiologic jaundice (normal, benign)
|
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How disting: Physiologic vs. breast milk jaundice? |
Physio appears d0 ––> peaks at d3 –– resolves d4
Breast milk: appears d4, peaks days 10-14 |
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|
Breast–milk jaundice: underlying mxn? |
INHIBITORY SUBSTANCE in milk ––> increase enterohepatic circulation
|
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|
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 |
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|
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
|
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Biliary atresia in neonate: Absent INTRA or EXTRA hepatic bile ducts? |
EITHER
|
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|
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
|
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|
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
|
|
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What GESTATIONAL AGE: highest risk of severe hyperbilirubinemia |
35–38!!!
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Jaundice: increased risk: Breast or formula |
Breast
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Jaundice: increased risk: M or F? |
Male
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Jaundice: increased risk: White or Asian? |
Asian (esp East Asian)
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Jaundice: increased risk: young or old mom |
>25yo mom
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Require further w/u? Neonatal jaundice + VOMIT |
Yes
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Require further w/u? Neonatal jaundice + fever |
Yes
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Require further w/u? Neonatal jaundice + ONSET AFTER D3 |
YES
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Require further w/u? Neonatal jaundice + high–pitched cry |
YES
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Require further w/u? Neonatal jaundice + bili <15 |
NO – suspect physio
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Jaundiced neonate: Does normal CBC rule out hemolytic dz? |
NO –––– order retic to check for anemia
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Breast milk: Contain growth factors? |
Yes
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#1 carbohydrate in breast milk |
Lactose
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See lactose intolerance in neonates? |
Uncommon 0–1yo
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Breast milk: Fats comprise what % calories? Most fat at beginning or end of feed? |
50%
Most fat at end (encourage baby to drain boob) |
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Breast milk: Contains what 2 proteins? |
Whey
Casein |
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Breast milk: More or less protein than cowmilk? |
3x cow > breast
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Do not give regular cow's milk until what age? What could develop? |
>1yo
Colitis --> microscopic bleeding --> anemia |
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Colostrum: produced which days? slowly or rapidly replaced by milk? |
d0–5
Slowly replaced by milk |
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Which has more: colostrum or breastmilk: –minerals –protein –fats –carbs –IgA |
Minerals: col
Protein: COLOSTRUM Fat: milk Carb: milk IgA: milk |
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Breast–feeding: affect incidence of: –SIDS? –Allergies? –DM? |
Breast ––> decrease incidence all
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Should mother expect menses while breastfeeding? |
NO – no ovulate
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Breast–feed: increase or decrease risk breast cancer in mother? ovarian cancer? osteoporosis? |
Decrease all
(since suppresses estrogen) |
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Breastfeed: Is it common for infant to fall asleep before finish feed? |
YES
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Breastfeed: How many feeds per day? How frequently? How many minutes each breast? |
8–12 feeds/day
Every 2–3h 15mins/breast |
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Breast milk contains all vitamins EXCEPT _____ |
Vitamin K
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Do breast–fed babies req suppl Vitamin D? |
Only if <15 min sun /week
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Fluoride: supplement at what age? Under what conditions? |
Suppl all infants >6mos if <0.3ppm
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Kernicterus: stain what structures? |
Basal ganglia & cranial nerve nuclei
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Kernicterus: do to high levels of conj or unconj bilirubin? |
Unconjugated
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Kernicterus: highest risk if 1st or subsequent episode of jaundice? |
Highest risk if FIRST episode of jaundice
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Bilirubin encephalopathy: see HYPO or HYPERtonia? |
TRICK
Hypotonia early ––> hypertonia late |
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What dz: yellow baby with hypotonia, loss of suck reflex, vomit ––> hypertonia, szs, ataxia |
Bilirubin encephalopathy (Kernicterus)
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Bilirubin encephalopathy: early OR late?: Hypotonia |
Early
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Bilirubin encephalopathy: early OR late?: Hypertonia |
Late
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Bilirubin encephalopathy: early OR late?: Opisthotonous |
Late
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Bilirubin encephalopathy: early OR late?: Szs |
Late
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Bilirubin encephalopathy: early OR late?: Deafness |
Late
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Bilirubin encephalopathy: increased risk in whites or Asians? |
Asians
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Bilirubin encephalopathy: Assoc w/prematurity? |
Increased risk if premature
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Bilirubin encephalopathy: Assoc w/altitude? |
Increase risk at high alt
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Bilirubin encephalopathy: What other medical problem is a risk factor? |
Small bowel obstruction
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How tx: Breast + jaundice + bili 16–25 |
Cont breast + observe
OR Suppl formula 24–48h + phototx |
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How tx: Term + jaundice + hemolysis + bili 17.5–23 |
Exchange transfusion
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Can you administer phototx while breast–feeding? |
YES
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Neonate w/hyperbili: can you lower via admin H2O/dextrose? |
NO
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Neonate: What day stop meconium ––> yellow BM |
day 3
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Neonate: what day: 3–4 stools/day |
By d6-7
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By d3–4 life: how many stools per day? how many wet diapers? |
3–4 stools
3–4 wet diapers |
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By d6 life: how many stools per day? how many wet diapers? |
3–4 stools
6 diapers |
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Return to birth weight at what age? |
2w
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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 |
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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 |
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Name for: Edema/serum over presenting part of scalp |
Caput succedaneum
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Caput succedaneum: where located? |
PRESENTING part of scalp (=edema)
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Caput succedaneum: Leads to hyperbili? |
NO –– overlies periosteum
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Anatomic difference b/w: Caput succedaneum & cephalohematoma |
Caput: edema overlies periosteum ––> NOT increase bili
Cephalo: SUBperiosteal hemorr (not extend suture line) ––> can cause hyperbili |
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Cephalohematoma: –where located in re: periosteum –cross suture lines? |
SUBperiosteal
NOT cross suture lines |
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Can you approximate the bilirubin level based on the extent of jaundice? |
YES
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Estimated bilirubin level when jaundice at face? Below knees? |
At face = 4-5mg/dL
Below knees = 10-15mg/dL |
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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 |
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Suspect what problem: Neonate 0–72h & anorexia/vomit/sz |
Inborn error of metab
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What fraction of sick, full–term neonates without infection risks have an underlying metabolic dz? |
20% !!! (1/5) ––– that's a lot
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Inborn error of metabolism: can appear insidiously? |
Yes
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Neonate screen: all states screen what 2 dzs? What method? |
PKU
Hypothyroid via tandem mass spec |
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Red reflux: see from how far away? |
1 foot
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Spleen: normally how far below L costal? Should you push to find tip? |
1–2 CENTIMETER below L costal
Never push to find tip |
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Ortolani & Barlow: 1st perform at what age? |
BIRTH
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Developmental Dysplasia of Hip: More common L or R? |
3x L > R
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Developmental Dysplasia of Hip: F or M? White or black? |
F
White |
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Developmental Dysplasia of Hip: Assoc w/birth position? |
More common BREECH
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Developmental Dysplasia of Hip: Genetic component? |
Higher risk if FHx DDH
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Neonate phys exam: Perform hip exam at what ages? (to assess DDH) |
0–3mos
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What test: Thumb on lesser trochanter ––> flex hip ––> downward pressure |
Barlow Test
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Barlow test: –where is thumb? –flex or extend hip? what degree? –ab/duct? |
Thumb on LESSER trochanter ––> flex to 90 ––> ADDuct & down
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What test: Abduct hip & push femoral head anteriorly |
Ortolani
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Ortolani maneuver: –ab/duct hip? –push fem head ant or post? |
ABDUCT (contrast Barlow – adduct)
Push fem head ANTERIORLY over greater troch |
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Barlow or Ortolani: Feel CLUNK |
Ortolani
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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. |
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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. |
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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. |
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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. |
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Congenital hypothyroidism: how affect ammonia level? |
No change (normal NH4)
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Newborn metabolic screen: uses what lab technique? |
Mass spec
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Screens for what dz: Measure immunoreactive trypsinogen |
Cystic fibrosis
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How define: Lethargy |
1. Decreased eye movements
OR 2. fail to recog parents or interact w/environ |
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Name for: Decreased eye movements & fail to interact w/parents or environ |
LETHARGY
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How define: FTT |
Fail to regain bw by 3 WEEKS or continuous wt loss after 10d life
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What is difference and which most common: 1' vs. 2' vs. 3' hypothyroidism |
1': thyroid dysfxn (95%)
2: pit 3: hypothal |
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Congenital hypothyroidism: most common what ethnicities? (2) |
Native Am
Hisp |
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Mxns of congenital 1' hypothyroidism |
Thyroid ectopy
A/hypoplasia Errors of thyroid hormogenesis |
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1' hypothyroidism: low or high TSH? |
HIGH
(HPA intact; prob is thyroid) |
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1' or 2/3' hypothyroidism: Low TSH |
2/3 (pit/hypothal not producing TSH ––> low T4)
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Does maternal thyroid hormone cross placenta? |
YES
Infant with congenital hypothyroid appears normal at birth due maternal thyroid |
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Congenital hypothyroidism: when do s/sx present? |
6 WEEKS OF AGE
appears late bc of placental transmission of maternal thyroid hormone |
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Congenital hypothyroidism: Constip or diarrhea? |
Constip
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Congenital hypothyroidism: How does skin appear? |
JAUNDICED, mottling
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Congenital hypothyroidism: Small or large fontanelles |
LARGE
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Congenital hypothyroidism: Hypo or hypertonia |
HYPO
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Congenital hypothyroidism: Hypo or hyperthermia |
Hypo
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Congenital hypothyroidism: What abdominal defect? |
Umbilical hernia
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Infant hypo or hyperthyroidism: See umbilical hernia |
Hypo
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What dz: Normal neonate ––> 6w age p/w feeding probs, jaundice, large fontanelle, hypotonia ––> large tongue, puffy myxedematous face & M.R. |
congenital hypothyroid
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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) |
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Congenital hypothyroid: initiate L–thyroxine ––> what is goal TSH? T4? |
TSH: 1 mU/ml
T4: upper 1/2 normal |
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Congen hypothyroid: measure T4/TSH how often? |
2w ––> 4w ––> q1–2 mos until 1yo ––> q2–3mos until 3yo ––> q3–12 mos until complete growth
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How obtain FONTANELLE SIZE? |
Avg length & width
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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) |
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Premature closure / Small Fontanelle assoc with…? |
Microcephaly
Craniosynostosis Hyperthyroidism Normal variant |
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Sunken fontanelle assoc with…? |
Dehydration
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Bulging fontanelle assoc with… |
Increased intracranial Pressure:
-meningitis -hydrocephalus -subdural hematoma -lead poisoning |
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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. |
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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. |
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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 |
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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. |
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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. |
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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. |
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Infant UTI: how obtain urine sample? |
CATH
(NOT bag specimen) |
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Fever: # |
100.5 (38)
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Name for: Viable bacteria in circulation |
Bacteremia
(not necessarily systemic dz) |
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Name for: Systemic dz 2/2 microorgs in circ |
Septicemia
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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 |
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Fever of unknown origin: present for how long? |
2w
(with 1w of failed w/u) |
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Occult bacteremia: definition (what tests) |
Pos blood cx despite normal:
1. CXR 2. UA 3. LP |
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Occult bacteremia: see in what age range? |
0–3yo
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Qualify as SERIOUS bacterial illness (SBI)?: Enteritis |
Yes
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Qualify as SERIOUS bacterial illness (SBI)?: PNA |
Yes
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Qualify as SERIOUS bacterial illness (SBI)?: Cellulitis |
Yes
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Qualify as SERIOUS bacterial illness (SBI)?: Osteomyelitis |
Yes
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Qualify as SERIOUS bacterial illness (SBI)?: Otitis Media |
No
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Meningismus: due to stretching of nerves in what SPACE? |
Subarachnoid
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Nuchal rigidity: in/vol? |
INVOL
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Name for: Extreme nuchal rigidity ––> hyperextend entire spine |
Opisthotonus
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What is it?: Opisthotonus |
Extreme nuchal rigidity ––> hyperextend entire spine
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Name for: flex hip & extend knee ––> pt resists knee extens |
Kernig
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Name for: flex neck ––> pt flexes knee & hip |
Brudzinski
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Difference b/w: Kernig Brudzinski |
Kernig: flex hip ––> resist knee EXTENSION
Brud: flex neck ––> automatic flex knee & hip |
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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 |
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LP contraindication: platelets <___ (#) |
<50k
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Must perform LP if fever <__ (what age)? |
1yo
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Does normal CSF definitively r/o meningitis? |
YES
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Febrile infant: Suspect UTI in what ages? |
2mo – 2yo
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Gastroenteritis: see low or high fever with: –viral –bact |
HIGH FEVER with both
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Upper resp infxn: see low or high fever? |
Can see high fever
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LOW PREDICTIVE VALUE |
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Viral infection: do most have ab/normal WBC? |
Most have NORMAL |
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UA: nitrites have high or low: –spec –sens |
HIGH SPEC (few FPs)
LOW SENS (many FNs) |
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UA: is a positive LE enough to dx UTI? |
No – only indicates that WBCs are in urine
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Voiding cysturethrogram (VCUG): order in which infants? |
ALL infants w/SECOND uti
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Vesicoureteral Reflux (VUR): is most mild/mod/severe? req tx? |
Most mild ––> spont resolve
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UTI in <1yo: what % have vesicourethral reflux? |
0.5
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VUR: affect risk of UTI? req ppx abx? |
Increase risk of UTI ––> GIVE PPX ABX (until VUR resolves or surg)
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VUR: what is alt way to monitor (if not want VCUG)? |
Periodic radionuclide cystograms
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UTI in infant: –duration? –route? –repeat urine cx? |
7–14d
po ––> IV if severe dehydr Repeat urine cx if no response after 2d |
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Pyelo: 2 most common pathogens |
E coli > enterococcus
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Pyelo: –2 best abx & route for INPATIENT –outpatient |
Gent + Amp INTRAVENOUS
, Ceftriaxone ––> TMP–SMZ bid (total 7–14d), alt=Cephalexin |
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Pyelo: what is disadvantage of: –Ceftriaxone –Ciprofloxacin |
Ceftriax: no cover enterococci (#2), pseudomonas
Cipro: damages articular cartilage (esp knees) |
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Nitrofurantoin: use in what type of UTI? |
Lower UTI (cystitis)
NOT pyelo |
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Sulfisoxazole: used to tx pyelo? |
No – resistance
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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). |
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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). |
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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. |
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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. |
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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. |
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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 |
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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 |
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Always consider what dz: HIGH fever x 5d.... |
Kawasaki
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Kawasaki: usually <___yo |
<4yo
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3 dzs with palmar rash |
Kawasaki
Syphilis RMSF |
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Kawasaki: requires how many findings? |
4 (in addition to fever)
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Kawasaki: where see rash (2)? |
Groin
PALMS |
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Kawasaki: what 2 eye findings? |
1. Conjuncitivitis w/out discharge
2. ANTERIOR uveitis (slit lamp) |
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Anterior uveitis 2/2 Kawasaki: –how detect (what test)? –minority or majority of pts? |
Slit–lamp
80% pts in 1st week |
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Strawberry tongue: what 3 dz? |
1. Kawasaki
2. Strep pharyngitis 3. Infectious mono |
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Kawasaki: see lymphadenopathy? |
YES
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What dz: HIGH FEVER x5d, groin rash, conjuncitivitis, strawberry tongue, puffy/peeling hands & feet |
Kawasaki
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Kawasaki: low or high fever? |
HIGH x 5d
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4 causes of UNILATERAL cervical adenitis (non–cancerous) |
1. Kawasaki
2. Cat Scratch 3. Pharyngeal infection ––> reactive node 4. Mycobacteria |
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Kawasaki: see uni/bilat lymphadenopathy? |
UNILAT
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SJS: –see conjuncitivitis? –what type of rash (name)? |
Conjunctivitis
Erythema multiform |
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#1 fatal tick dz |
RMSF
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RMSF: how transmit? |
Tick
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RMSF: what type of rash? where located? |
Petichial rash on palms
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What dz: Petechial rash, HEADACHE, fever, myalgia |
RMSF
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Kawasaki: see change in CBC? |
1. INCREASE WBC, esp PMNs
2. Normocytic, normochromic anemia 3. Increase platelets (week 2) |
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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 |
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Kawasaki: see changes in LFTs? |
INCREASE (nonspecific)
decrease albumin |
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Suspect what dz: Increased WBC (esp PMNs), normo normo anemia, increased platelets, increased LFTs, STERILE PYURIA |
Kawasaki
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Kawasaki: what UA change? how collect UA? |
STERILE PYURIA (2/2 sterile urethritis)
Collect via CLEAN CATCH (would not detect pyuria by cath) |
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Kawasaki: order what imaging test? |
Baseline ECHO ––> repeat ECHO 4 weeks
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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) |
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Kawasaki: see CNS complications in what % pts? |
90%: lethargy, aseptic meningitis
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Kawasaki: see coronary art aneurysm in what % untx pts? |
0.25
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Kawasaki: what GI complication? (2) |
Liver dysfxn (40%)
Gallbladder hydrops (10%) |
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Kawasaki: after discharge ––> when return for repeat ECHO? |
Echo at weeks 0 & 4
(usually return 2 weeks after discharge for repeat) |
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What pathogen: Vesicular rash on hands & feet; ulcers in mouth |
COXSACKIE (enterovirus) ––> hand–foot–mouth dz
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What pathogen: Hand–foot–mouth dz |
Coxsackie (enterovirus)
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What pathogen: Prodrome fever >101 ––> cough, runny nose, conjunctivitis ––> maculopap rash behind ears ––> reaches feet |
MEASLES
3Cs |
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Measles: describe rash lesions & distrib |
Maculopap
Starts behinds ears ––> reaches feet w/in 2 days |
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Meningococcal rash: itchy? |
YES
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What pathogen: High fever 3d ––> fever ends ––> rash on trunk ––> spreads arms, neck |
Rubeola
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Rubeola: which see first: Rash or fever |
Fever ––> fever ends ––> trunk rash
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Rubeola: describe rash lesions & distrib |
Maculopap on trunk ––> spreads arms/neck
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Fever ends before rash appears
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Rubeola: usu <__yo |
<2yo
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Strep pharyngitis (GAS): 2 systemic comps |
1. Scarlet fever (blanching sandpaper)
2. Rheum heart disease |
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What pathogen: Blanching sandpaper rash & high fever |
Strep pharyngitis ––> Scarlet fever
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Scarlet fever: low or high fever? |
HIgh
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Scarlet fever: describe rash |
blanching sandpaper
starts groin/ax/neck ––> spreads |
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Scarlet fever: rash resolves how long? |
<10d
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Rheumatic fever: develops how long after strep infection? |
18 days
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What disease?: Jones Criteria |
Rheumatic fever
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Rheumatic fever: was diagnostic criteria (eponym)? req how many (#) criteria? |
Jones criteria
1 major + 2 minor 2 major + 1 mintor |
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What dz: Migratory polyarthritis, peri/myocarditis, erythema marginatum, subQ nodules & chorea |
Rheumatic fever (2/2 strep pharyngitis)
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Rheumatic Fever: –what type of arthritis? –name for classic rash –what neuro disorder |
MIGRATORY polyarth
Erythema marginatum Sydenham's chorea |
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Rheumatic Fever: what EKG finding? |
Prolonged PR
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What viral exanthem: EKG – prolonged PR |
Rheumatic Fever
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What dz: Complication: peritonsilar abscess |
Strep pharyngitis
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VZV: starts where on body? |
Trunk
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VZV: resolves after how long? |
1 week
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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. |
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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. |
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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. |
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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. |
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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. |
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Asthma vs Reactive Airway Disease |
RAD = Asthma in children under 3yo
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What is most ominous finding of respiratory distress? |
PARADOXICAL BREATHING
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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 |
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Name for sound: Forced expiration against a closed glottis |
Grunting
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Grunting: due to what action? |
Forced EXPIRATION against closed glottis
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Grunting: see in what 3 lung dzs? |
1. Atelectasis
2. PNA 3. Pulm edema |
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Head–bobbing in resp distress: synchronized with INSP or EXP? |
INSP
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Name for resp sound: musical, CONSTANT PITCH, loudest at neck |
STRIDOR
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Stridor: –constant or variable pitch? –where ausc loudest? –lower or upper aw? |
Constant pitch (musical)
Loudest at neck Upper aw |
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Stridor: see with insp, exp or both? |
INSP ONLY
(according to CLIPP) |
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Difference between: Wheeze vs. rhonchi |
Basically same mxn
Wheeze: high pitch Rhonci: low |
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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 |
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What resp sound: Only hear during EXP or EXP+INSP (never insp alone) |
Wheeze/rhonchi
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Wheeze/rhonchi: does longer & higher pitch indicate more severe dz? |
YES
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Crackles: dis/continuous? |
DISCON
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Crackles: sound differences b/w coarse & fine |
Coarse: low pitch, loud, few
Fine: high pitch, quiet, many |
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Lower or upper aw obstrution: Wheeze |
Lower
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Lower or upper aw obstrution: Prolonged expiratory phase |
Lower
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Lower or upper aw obstrution: VIRAL URI |
LOWER!!!!
(see wet cough, no wheeze) |
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Viral URI: common to see wheeze? |
NO
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Asthma: is wheeze severity correlated with asthma severity? |
NO
If severe asthma with no air exchange ––> no wheeze (BEWARE) |
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Severe asthma ––> what CV change? |
Pulsus paradox
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What dz: CXR shows: Bilat hyperinflation, flat diaphs, atelectasis |
Asthma
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Lower or upper aw obstrution: Acute bronchiolitis |
LOWER
Edema/mucuus ––> obstruct bronchioles |
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Lower or upper aw obstrution: Pertussis |
LOWER
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Acute bronchiolitis: What % due RSV? |
0.5
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Acute bronchiolitis: In addition to RSV – what other viruses? |
para/influ
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Acute bronchiolitis: See what temps? (#) |
38.5 – 39
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Acute bronchiolitis: See wheezing? |
YES
(contrast VIRAL URI) |
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Acute bronchiolitis: How appear CXR? |
Bilat hyperinflat (sim asthma) w/scattered atelect
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Asthma: due inflamm/edema of mucosa or parenchyma? |
Mucosa
(contrast PNA – parenchyma) |
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Pneumonia: what BACTERIAL pathogen: –5–6yo (#1) –school age (#1–2) |
5–6yo: Strep pneumo
School: MYCOPLASMA #1, Strep pneumo #2 |
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Viral pneumonia: what 4 viruses common? |
RSV, para/influ, adeno
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Indicates what dz: Crackles |
PNA (bact or viral)
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Chlamydia trachomatis PNA: presents how long after birth? |
3–4w
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Whooping cough: what pathogen? |
Bordatella pertussis
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Bordatella pertussis: vaccine is how effective? (%) |
70–90%
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What pathogen/dz: 3 stages (catarrhal, paroxysmal, convalescent) |
Bordatella pertussis
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Bordatella pertussis: 3 stages & duration of each |
1. Catarrhal: 1–2w (URI sxs)
2. Paroxysmal: 4–6w (staccato) 3. Convalescent: mos cough |
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What dz: Staccato cough |
Bordatella pertussis (whooping)
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Bordatella pertussis: cough may persist how long? |
Paroxysmal cough 4–6w ––> regular cough for mos
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Lower or upper aw obstruct: Foreign body |
Upper
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Lower or upper aw obstruct: Epiglottitis |
Upper
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What dz: Asymmetric wheeze in 5yo w/out hx aw dz |
foreign body
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Foreign body asp: most common location |
R mainstem bronchus
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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
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Treatment for foreign body aspiration? |
Rigid bronchoscopy
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Epiglottitis: what age group? |
2–5yo
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Lower or upper aw obstruct: Croup |
TRICK – both (subglottic)
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Croup: caused by 6 pathogens |
Para/influ
Adeno RSV MYCOPLASMA MEASLES!!!! |
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Indicates what dz (general name): Insp stridor + barking cough |
Croup
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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. |
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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. |
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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. |
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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. |
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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). |
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If atopic parent ––> what is risk to child? (%) |
30% risk
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Has rate of asthma increased in recent years? |
2x increase in 15 years
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#1 chronic dz in peds |
asthma
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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 |
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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 |
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Asthma: wheeze in what part of resp? |
End–expiratory
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How do allergies ––> chronic cough? |
Allergy ––> nasal congest ––> PND ––> noct cough
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What dz: COBBLESTONE post pharynx |
Allergies: PND ––> lymphoid hyperplasia
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Allergic rhinitis: what TYPE of hypersens rxn? |
Type 1 (immed)
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Allergic rhinitis: how tx? (2) |
Antihistamine
topical nasal steroids |
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What is this: often preceded by URI, nocturnal cough, PND, bilateral purulent nasal secretions, malodorous breath |
Sinusitis
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Sinusitis: req sxs how long? |
1week purulent nasal discharge
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Sinusitis: see fever? |
YES
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Sinusitis: nose & throat swabs useful? |
No
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Sinusitis: 4 most common bact |
S pneumo
H flu M catar Strep PYOGENES |
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Sinusitis: tx with what class? |
B–LACTAMS
–cefuroxime –augmentin |
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What is this: presents like Sinusitis but UNILATERAL symptoms |
nasal foreign body
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When develop: –ethmoid sinuses –max sinuses –frontal |
Ethmoid & max: at birth
Frontal: 6–8yo |
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What is this: extension of viral inflammation into lower respiratory tree, prolonged congested cough with URI sxs |
Bronchitis
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Bronchitis: s/sx worse day or night? |
EQUAL
(no change w/temp,exercise) |
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Think what dz: Rhonchi |
Bronchitis
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Atypical/viral PNA: s/sx change w/temp, exercise? |
MAY WORSEN
(contrast Bronchitis) |
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Atypical/viral PNA: expect cough for how long? |
8–12w
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How does GERD ––> nasal congestion? |
NASAL reflux ––> congest
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Habitual cough: what is initial trigger? |
Viral URI
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What dz: Brassy, short, dry spasmodic cough; no change w/exercise, cold; resolves w/sleep |
Habitual cough
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Fungal pulm infxn: dry or wet? |
DRY
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Chlamydia PNA: intermittent or paroxysmal cough? |
Parox! (violent attacks)
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Mycoplasma PNA: intermittent or paroxysmal cough? |
Parox! (violent attacks)
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Suspect what dz: Chronic cough + palpitations |
CHF
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Suspect what dz: Chronic cough + abdominal pain |
PNA
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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) |
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Due obstruction in small/med/large aw: Rhonchi |
Large
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Due obstruction in small/med/large aw: Wheeze |
Mod
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Due obstruction in small/med/large aw: Rales |
Small
(contrast rhonchi: large) |
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Difference between: Variable & fixed obstruction |
Variable: insp OR exp only
Fixed: BOTH insp & exp |
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If immunized child w/chronic cough ––> suspect pertussis? |
Unlikely
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Fungal PNA: –is cough productive? disturb sleep? –chest pain? |
Non–productive cough, not disturb sleep
PLEURITIC chest pain |
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What type of cancer can present with chronic cough? |
Mediastinal lymphoma
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Child with 1' TB: See what changes on CXR? |
FEW/NO CHANGES
(little evidence of initial focus) May see focal hyperinflat, atelect |
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Suspect what dz: *Large regional lymphadenitis + non–productive cough + FTT + fever/congestion |
1' TB
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Common sequence seen in pediatric TB? |
1. Hilar adenopathy (most common xray finding)
2. Focal hyperinflation 3. Atelectasis |
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Pediatric Tb: see small or large regional lymphadenitis? |
LARGE
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Pediatric TB: which lobar segments at increased risk? |
EQUAL RISK
2+ foci in 25% pts |
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Pediatric TB: see local effusions on CXR? |
YES
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If suspect TB and pt is symptomatic ––> how officially dx? |
sputum cx OR 1st AM gastric asp
(positive PPD also useful in ped) |
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What size: Positive PPD in LOW–risk / asymptomatic child |
>15mm
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Asthma: how tx: Mild intermittent |
B–agonist
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Asthma: how tx: Daily persistent asthma |
B–agon + inhaled cortico
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Inhaled corticosteroid: how long until see improvement? |
few weeks
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Asthma: if Leukotriene inhibitor corticosteroids ––> monitor what 4 things? |
1. BP (HTN)
2. Blood glucose 3. Growth 4. Cataracts |
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Asthma: does administration of leuko–synth inhibitor affect the req dose of inh steroid? |
allows lower dose steroid
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Asthma: which more effective: Inh steroid or leuko–inh |
STEROID
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Asthma: can you use leuko–inh as monotherapy? |
NO
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If see CXR with mediastinal/hilar adenopathy ––> think what 3 dzs? |
1. TB
2. Fungal PNA 3. malig |
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Obstructive or restrictive: Decrease FEV1/FVC |
Obstruct
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Asthma: decrease or normal FEV1/FVC |
Decrease
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Obstructive or restrictive: SLE |
Restrictive
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Obstructive or restrictive: Normal FEV1/FVC |
Restrict
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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. |
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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. |
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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. |
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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. |
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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. |
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Name for: Mid ear fluid + s/sx ear infxn (bulge, drainage) |
ACUTE OM
(contrast OME = NO s/sx of infxn) |
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How different: AOM vs. chronic OME (OM with effusion) |
AOM: fluid + s/sx
Chronic OME: fluid – s/sx |
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AOM: 4 most common bact pathogens |
#1 Strep pneumo
#2 H flu M cattarhalis Strep Pyogenes |
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AOM: 3 common VIRAL pathogens |
Influ
RSV Rhino |
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AOM: higher bottle or breast? Assoc w/pacifier? genetic component? |
Bottle
Increase risk if pacifier FHx |
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AOM: M or F? |
M > F
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AOM: assoc w/SES? |
Increased in LOW SES
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AOM: highest what ethnicity? |
Native American
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What dz: TMs retracted & amber & decreased mobility |
Chronic OME
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Ear exam to r/o AOM: which is more reliable: TM color OR position/mobility |
Position/mobility
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Ear exam: Is RED TM alone a good predictor of AOM? |
NO
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What test: Objective eval TM mobility |
Tympanogram
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What test: Audio thresholds via EARPHONES |
Conventional audiometry
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What test: Audio threshold via SPEAKERS |
Visual Reinforcement audiometry (VRA)
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How different: Conventional audiometry vs. Visual Reinforcement Audiometry |
Conventional: earphones; >4yo
Visual: speakers; 6mo – 2.5yo |
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Conventional audiometry: can perform in what ages? |
>4yo
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Visual Reinforcement Audiometry: perform in what ages? |
Speakers
6mo – 2.5yo |
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What test: PHYSIOLOGIC test of COCHLEAR response to stimulation |
Otoacoustic Emissions (OAE)
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What test: Use in newborn to assess hearing |
Otoacoustic Emissions (OAE)
–physio test of cochlear response |
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AOM: what % resolve spontan? |
50–80%
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AOM: Tx for DEFINITE dx in: 0–2yo >2yo |
If unilateral AOM:
0–2yo: abx >2yo: abx if SEVERE (39C, pain) Bilateral AOM --> abx |
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UNCERTAIN AOM: must give abx if <___ (age) |
<6mo
If 6mo –2yo ––> you can observe (abx if 39', severe pain) |
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Abx of choice for AOM? |
Amoxicillin
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Chronic OME: assoc w/hearing loss? |
YES ––> lang delay
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Chronic OME: how tx? (2 options) |
watch & wait
if hearing loss ––> TUBES |
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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. |
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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. |
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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. |
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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. |
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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. |
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Hypernatremia: slow or rapid replace fluid? |
SLOW!
Decrease Na 1 mEq / 2h (10 mEq/d) |
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Leads to what lyte abn: Drink boiled milk |
Hypernatremia
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Leads to what lyte abn: Drink free H2O |
Hyponatremia
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How calculate: Degree of dehydration (#) |
Previous wt – current wt
(assumes all wt loss is free H2O) |
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Expect hypo/iso/hypernatremic loss: Gastroenteritis |
ISOnatremia
(not req to measure lytes) |
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Gastroenteritis: required to measure lytes? |
No – only if mod/severe dehydr
(assume isonatremic loss) |
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Dehydration: give what SIZE BOLUS over what AMT TIME? repeat boluses how often? |
20 cc NS over 20–60min
Repeat until normal UOP & HR |
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How calculate: Fluid deficit (cc) = |
wt (g) x % dehydration
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Dehydration: if replace fluids ORALLY ––> how many CCs per how much TIME? |
5–10cc q 1–5min
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Give how much maintenance fluid?: 8kg |
8x100 = 800cc/d
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Give how much maintenance fluid?: 14 kg |
10x100=1,000
4x50=200 1,200 |
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Give how much maintenance fluid?: 25 kg |
10x100=1,000
10x50=500 5x20=100 1,600 |
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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 |
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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 |
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Fluid balance: Need to replace HOW MUCH fluid for stool loss? What type of fluid? |
>5g per 4h
Use 1/2NS + 20KCl (no dextrose) |
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Normal saline: how much Na+? Cl? |
154 each
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Oral replacement therapy: able to use in MODERATE dehydration w/out vomit? |
YES
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Dehydration: when reintroduce breastmilk/full formula? |
If no vomit & tolerates 1–2 ozs of ORT per feed
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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. |
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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). |
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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 |
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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. |
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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. |
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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 |
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DKA: see OSMOTIC DIURESES once Blood Glucose is above what #? |
180
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DM: screen if overweight (WHAT BMI %) and HOW MANY SXS? |
BMI >85% and 2 s/sx
(FHx 1–2', race, HTN, dyslipid,etc) |
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DM: screen beginning what age? how often? |
puberty ––> q3 yrs
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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 |
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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) |
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DKA: follow what LAB to monitor response to insulin? |
SERUM ketones
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What dz: Increased beta–hydroxybutyrate |
DKA
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DKA: monitor URINE KETONES how often? |
Every void until no ketones
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DKA: how decide when to switch from IV to SQ insulin? |
Switch once NO KETONES In serum or urine
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DKA: how affect BUN, CR? |
Usually normal
Increase if severely dehydrated |
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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 |
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DKA: admin K+ in IVF? |
YES – give K+
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DKA: cont insulin drip until: –pH > # –bicarb > # |
pH > 7.3
Bicarb > 15 |
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DKA: add DEXTROSE to IVF if BG <___ |
<300
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DKA: what is tx goal: –RATE of BG drop –Target BG |
Decrease 80–100 mg/dl per HOUR
Goal: 120–250 |
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DKA: #1 reason of death |
Cerebral edema 2/2 overrapid glucose correction
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What dz: Child w/DKA ––> give insulin drip ––> HA & mental status change ––> death |
Cerebral edema 2/2 overrapid correction
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Cerebral edema 2/2 overrapid correct DKA: –admin what drug to prevent? |
MANNITOL IV 0.25–1mg/kgDue
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Do children have lower or higher % total body H2O? |
HIGHER
(increases risk of dehydration) |
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Dehydration: low or high sensitivity?: Decreased UOP |
HIGH
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Dehydration: low or high sensitivity?: Dry mucus membranes |
HIGH
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Dehydration: low or high sensitivity?: Absent tearing of eyes |
HIGH
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Hypo/iso/hypernatremic dehydration: Gastroenteritis |
ISO
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Dehydration: correct over how many hours?: –hyponatremic –iso –hyper |
Hypo: 24h
Iso: 12h Hyper: 24h |
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How define (what serum Na+): –hyponatremic –hyper |
Hypo: <130
Hyper: >150 |
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If severe hyponatremia (<120): think what 3 etios? |
1. Free H2O
2. Dilute formula 3. Adrenal insuff |
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Hypo/iso/hypernatremic dehydration: D.I. |
Hyper (>150)
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Insensible losses (evaporation) account for what % daily H2O req? |
40%
(other 60% is UOP) |
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DKA: do you replace ongoing urine loss? |
NO – mobilizing extracellular fluid
(you do replace stool losses) |
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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. |
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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. |
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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). |
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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. |
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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. |
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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. |
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How distinguish: Trans synovitis of hip VS septic hip |
DEGREE of inflamm (based WBC, ESR, CRP)
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Transient synovitis of hip: Common? |
YES
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Transient synovitis of hip: LT sequela? |
None
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Transient synovitis of hip: Low or high fever? |
Low
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Transient synovitis of hip: Affect ROM? |
DECREASED ROM
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Transient synovitis of hip: How long until resolve? |
3–4d
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Transient synovitis of hip: How tx? |
rest + ibuprofen ––> f/u 2d to recheck CBC (r/o leukemia)
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Can septic arthritis lead to avasc necrosis? |
Yes – accum pus ––> pressure ––> decrease BF fem head
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Septic arthritis: which pathogen common in neonate? |
GBS
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Septic arthritis: which pathogen in adol? |
N gonorr
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Septic arthritis: which species of strep? |
Strep pyogenes
Strep pneumo |
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Septic arthritis: see joint warmth? redness? |
Not always (since deep infxn)
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Septic arthritis: joint asp has DECREASED or INCREASED viscosity? |
DECREASED viscosity indicates infxn
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Septic arthritis: how tx? |
I & D! ––> IV abx ––> repeat asp
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JRA: difference between: Pauci & polyarticular |
Pauci: <4 (usu large)
Poly >4 (usu small) |
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JRA: are all subtypes assoc w/fever? |
No, only some
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JRA: common to see rash? |
YEs
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JRA: dx requires s/sx to be present for how long? |
6+ weeks
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What dz: Infxn ––> Abs against joint |
REACTIVE (post–infectious) arthritis
(NOT transient syno: inflamm of lining – no actual Abs) |
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Reactive arthritis: Presents how long after initial infxn? |
Few weeks
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Reactive arthritis: due to what PATHOGENS: –GI infxn (2) –GU infxn –Pharyngitis |
GI: Yersinia, Shigella
GU: Chlam Strep |
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What dz: Joint pain + asp w/inflammatory cells + NEGATIVE asp cx |
Reactive arthritis
(contrast septic: pos asp cx) |
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Reactive arthritis: How tx? |
ABX IF INFXN STILL PRESENT
otherwise NSAIDs for few wekes |
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Reactive arthritis: More common lower or upper extrems? small or large joints? |
Lower
Small |
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Sprain: what anatomic injury? |
Tear ligament
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See SPRAIN after fall? |
NO
Req tearing motion |
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Occult fx: see how long s/p injury? |
3–4w
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Osteomyelitis: #1 pathogen |
Staph aureus
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Osteomyelitis: ACUTE or INDOLENT pain? |
INDOLENT!!!
Delays abx 5–10d |
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Osteomyelitis: what % pts present with fever but no pain? |
0.5
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Suspect what dz: Limp + jaw pain |
Leukemia w/BM infil
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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. |
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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. |
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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. |
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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. |
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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. |
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VSD: why not present in neonate? |
High pulm vasc R in neonate ––> no reason for blood to shunt to pulm vasc rather than systemic
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VSD: how result in poor feeding? |
LV overload ––> CHF ––> increased RR ––> difficult feeding
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What dz: Sweat during feed; tire during feed |
CHF (e.g. 2/2 VSD)
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CHF: #1 phys finding |
TACHYPNEA
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What dz: Tachycardia w/gallop rhythm |
CHF
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VSD: is murmur intensity correl with size of defect? |
NO
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What MURMUR: Loud, blowing holosystolic at LLSB |
VSD
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VSD: when present? |
Few days s/p birth
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VSD: where best ausc? |
Lower left sternal border
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VSD: does magnitude of shunt affect the age of presentation? |
YES
larger defect ––> earlier CHF |
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VSD: defect becomes smaller or larger with time? |
SMALLER
(75% small & 50% total will close) |
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VSD: what % total close? |
50%
(75% small VSDs) |
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VSD: expect abn EKG? |
YES – see RV dominance
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4 defects that cause murmur AND CHF |
1. VSD
2. Ao stenosis 3. Ao coarct 4. large PDA |
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Lead to CHF?: PDA |
Yes (if large)
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Lead to CHF?: ASD |
No
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Lead to CHF?: TOF |
No
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Infant CHF: req inpatient tx? |
YES
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How tx: –CHF due VSD –CHF due cardiomyopathy |
VSD: digoxin + furesomide
Cardiomyo: ACE–I |
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VSD: decide surgery at what age? |
6mo
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Gallop: common in peds? |
No
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What murmur: Continuous diastolic murmur |
PDA
(PATHOLOGIC) |
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Common or rare?: Endocarditis |
Rare
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Common or rare?: Cardiomyopathy |
Rare
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Innocent murmurs: common what age? due to defect? |
3–7yo
NOT defect (due vibration) |
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#1 innocent murmur |
Still's
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What murmur: musical, vibratory murmur in LSB while supine |
Still's (innocent)
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Still's murmur: best heard standing or supine? |
SUPINE
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What murmur?: Widely split, fixed S2 |
ASD
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ASD: presents what ages? |
3–5yo
(contrast VSD: few days s/p birth) |
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What murmur: Presents 3–5yo |
ASD
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What murmur?: Initially syst ejection murmur ––> early diast murmur |
Ao stenosis
(leads to Ao insuff) |
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What murmur?: S1 ––> systolic ejection click ––> harsh systolic murmur |
Pulmonic stenosis
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PDA: louder in dias or syst? |
SYST loudest
(although continuous) |
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What murmur?: Holosystolic, blowing |
VSD
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What murmur?: PROGRESSIVE; detect any age; p/w HTN in upper extrems |
Ao coarct
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Detect what age: Bicuspid Ao valve |
Adol/adult
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1st & most subtle sign of inadequate circulation |
tachycardia
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Femoral pulse: represents periph or central pulse? |
Central
(sim carotid) |
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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. |
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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). |
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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. |
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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. |
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Cerebral palsy: Progressive? |
No
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Cerebral palsy: Defining feature |
Decreaesed motor control
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Cerebral palsy: is spasticity dependent on velocity? |
YES – greater resistance w/rapid movement
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Cerebral palsy: is resistance greater with SLOW or RAPID movement? |
RAPID
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Cerebral palsy: in/decreased tendon jerks |
INCREASED
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What dz: See spastic diplegia |
C.P.
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Name for: Increased tone, esp in lower extrems |
Spastic diplegia
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Spastic diplegia: assoc w/prematurity? |
Yes
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Leads to what TYPE of cerebral palsy: –birth asphyxia –kernicterus |
Both lead ot DYSKINETIC cerebral palsy
(NOT other types) |
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Cerebral palsy: see pts with GLOBAL developmental delay? |
No – just motor
GDD = cogn disabl/MR |
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MR/cognitive disability: possible to see FHx? |
Yes – if 2/2 inborn error metab
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Abn development 2/2 neglect: See improvement if stop abuse? |
YES
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Do premature babies have increased risk of abuse? |
Yes
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Myopathy: p/w gross or fine motor abns? |
BOTH
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What class of dz: abn tone, fasciculations, weakness |
Myopathy
(NOT CP – see spasticity, increased tendon jerks) |
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Cerebral palsy: how dx? |
MRI & assessment by developmental specialist (use Bayley scales of infant development)
(determines etio of abn neuro exam) |
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What dz: Upslanted palpebral fissures |
Downs
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What dz: –small ears –low–set ears |
Small: Downs
Low: Turner's |
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What dz: Epicanthal folds |
Downs
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What dz: Redundant nuchal skin |
Downs
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#1 M.R. involving genetic material |
Downs (21)
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Down's: 3 genetic mxns |
Trisomy (#1, regardless mat age)
Unbalanced translocation Mosaic for 21 |
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Down's: ABSOLUTE risk higher in young or old mothers? |
YOUNG
(relative risk higher in old) |
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Downs: how dx? |
Leukocyte karyotype
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What dz: Micropthalmia, microceph, polydact, cleft lip & palate, umbilical hernia, CUTIS APLASIA |
Patau (13)
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Patau (13): defects in what organs? (2) |
Cardiac
Renal Also: microceph, polydact, clefts, umbilical hernia, cutis aplasia |
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#1 FAMILIAL cause of M.R. |
Fragile X
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Fragile X: what repeat? |
CGG outside FMR1 coding regions
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What dz: larges testes; large everted ears; long face w/large mandible |
Fragile X
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Turner's syndrome: see physical differences at birth? |
Yes
|
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What dz: See lymphedema in utero |
Turner XO
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What dz: web neck, low ears, hyperconvex nails, shield chest |
Turner XO
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Turners: What is feature of nails? |
Hyperconvex
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Turners: Ao coarctation in what %? |
0.2
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Turners: How affect IQ? |
NORMAL IQ
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How dx: Benign Neonatal Hypotonia |
Dx of EXCLUSION
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Benign Neonatal Hypotonia: px? |
Good; gradual increase tone
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Down's: what is most consistent finding at birth? |
HYPOTONIA ––> poor feeding
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Down's: recommended imaging at birth? |
ECHO
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Down's: recommended blood test? |
TSH
(6mo ––> q 1 year) |
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Down's: what skeletal abn? |
Atlanto–axial instab
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Down's: predisp what cancer? |
Leukemia
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Hypotonia in infant: Tend to FLEX or EXTEND extrems? |
Extend (passive)
(noxious stim ––> won't flex) |
|
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Hypotonia in infant: see in/decreased primitive reflexes? |
DECREASED
(since hypotonic) |
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Hypoxic–ischemic encephalopathy 2/2 perinatal injury: more commonly see HYPO or HYPERtonia? |
HYPER
(although can see hypo) |
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Suspect what dz: Normal neonate ––> 2–4w later see lethargy, fever, HYPOTONIA |
SEPSIS 2/2 GBS
|
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#1 etio ambiguous female genitalia |
Congen Adrenal Hyperplasia
|
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Congen Adrenal Hyperplasia: how inherit (pattern)? |
AR
|
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Congen Adrenal Hyperplasia: defect what hormone? |
Cortisol synth
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Congen Adrenal Hyperplasia: #1 type |
21–OH deficiency
Decrease cortisol, aldo Increase 17–OH progest ––> increase androgens |
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21–OH deficiency: –decrease production which hormones? (2) –increase production which hormone? effect? |
Decrease cortisol, aldo
Increase 17–OH progest ––> increase androgens ––> verilize fems |
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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 |
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Classic CAH: sxs appear what age? |
1–2w
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CAH: what lyte abns? (2) |
HypoNa+
HyperK+ |
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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
|
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What dz: 1+/2+ protein during FEVER or EXERCISE |
Benign proteinuria
|
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Benign proteinuria: how define? |
1+/2+ protein during fever or s/p exercise
|
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What dz: Only excrete protein when standing (1,500mg/d) |
Orthostatic proteinuria
|
|
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Orthostatic proteinuria: indicate renal dz? |
NO – common in adols
|
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Orthostatic proteinuria: see in AM? |
NO – first AM urine should be negative since lying down ––> not spillling protein
|
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Common to see generalized tonic–clonic szs in newborn? |
NO – contrast older infants
|
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Neonatal sz: see horizontal or vertical deviation? |
Horiz
|
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Suspect what phenomenon: Neonate w/eye jerking, lip–smacking, tonic limb posturing, APNEA |
SEIZURE
(subtle s/sx) |
|
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Ankle clonus: what is normal # beats? |
<10
|
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Clonus: what is abn # beats in a 1–2mo old? |
>3 beats is abnormal
|
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Indicates what process: –schistocytes –helmets |
Hemolysis (both)
|
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Nephrotic syndrome: –what age? –M or F? |
1.5–8yo
M >F |
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Nephrotic syndrome: #1 etio |
MCD
|
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Nephrotic syndrome: Fluid moves from ___ to ____ |
Lose albumin in urine –––>
Fluid moves from VASC to INTERSTITIUM ––> hypovolemia |
|
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Nephrotic syndrome: How affect BP? |
NORMAL BP
Retain H2O but fluid moves out of vasc into interstitium |
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How affect BP: –Nephrotic syndrome –Acute glomerulonephritis |
Nephrotic: normal BP
Acute GN: HTN |
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Acute glomerulonephritis: #1 presenting s/sx |
Tea colored urine
|
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Nephrotic synd and/or acute glomerulonephritis: Gross hematuria |
acute nephritis
|
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Nephrotic synd and/or acute glomerulonephritis: preceded by URI |
acute nephritis
|
|
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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 |
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|
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
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Shock: initial bolus (size & fluid) |
20 cc ISOTONIC NS
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Shock: When initiate INTRAOSSEOUS access? |
Fail periph: 90 seconds or 3 attempts
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IV access in SHOCK: What TYPE of central line is an approp alternative to periph line in older child |
FEMORAL
(NOT subclavian or arterial) |
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Meningococcemia: 1st choice abx |
IV PENICILLIN
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Meningococcus: how prophylx: –adult contacts –children |
Adult: cipro
Children: rifampin |
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Meningococcemia: admin what abx at discharge to elim carrier state? |
CEFTRIAX
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MCV4: safe what ages? |
11–18yo
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Meningococcemia: –what % adols die? total die? –what % have comps? |
Fatal 25% adols, 10% total
10–20% comps |
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Dehydration: when reintroduce breastmilk/full formula? |
If no vomit & tolerates 1–2 ozs of ORT per feed
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Where is pathology: BILLIOUS vomit |
POST–AMPULLA
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Where is pathology: Bloody vomit |
Above ligament of Treitz
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#1 etio gastroenteritis |
Rotavirus
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Pyloric stenosis: When present? |
3w (1w – 5mo)
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Pyloric stenosis: Bilious? |
No – immed vomit
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Pyloric stenosis: Where palpate olive? |
Above & right umbilius
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Pyloric stenosis: See skin changes? |
Often see jaundice
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Pyloric stenosis: What lyte abn? |
Hypochloremic metabolic alkalosis
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Pyloric stenosis: What imaging? (2) |
Abd U/S ––> (if not avail) ––> upper GI WITH CONTRAST
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What dz: Upper GI: STRING SIGN |
Pyloric stenosis
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Pyloric stenosis: Does LACK of palpable olive ––> affect suspicion? |
YES ––– speaks strongly AGAINST P.S.
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Pyloric stenosis: See diarrhea? |
No
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UTI: see vomit? diarrhea? |
Vomit yes,
no diarrhea –– may see loose stools |
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Gastroesoph reflux: see poor wt gain? |
Baby can develop food aversion ––> FTT
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Baby w/normal growth ––> acute vomit: Suspect metabolic disorder? |
Not if previously normal growth
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HSP: –peaks what age? –M or F? |
4–6yo (range 2–17)
2x M > F |
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HSP: underlying mxn? |
viral/bact URI (50% pts )–––> IgA–mediated
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HSP: how affects platelts? |
NORMAL PLATELETS!!!!
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What dz: URI ––> IgA deposition ––> leukocytic vasculitis |
HSP
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What dz: erythematous macules/wheals ––> petechiae ––> purpura |
HSP
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HSP: where see purpura? (distrib) |
Gravity–dependent & pressure–sensitive areas
ELBOWS, LOWER EXTREMS |
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HSP: what % pts have skin s/sx? |
1
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HSP: order what 2 labs? |
UA: ALWAYS; assess renal involve
(if see blood/protein ––> order BUN, CR) CBC: see NORMAL PLATELETS |
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HSP: see splenomeg? |
No
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HSP: req PT? PTT? Blood cx? |
NO
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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 |
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ITP: more or less common than HSP? |
LESS COMMON
(5:100k compared to 10:100k) |
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ITP: –age? –M or F? |
2–5yo (younger than HSP)
M=F |
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What dz: non–specific viral infxn ––> anti–plt Abs that bind plt surface ––> liver & spleen destroy plts |
ITP
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HSP or ITP: YOUNGER |
ITP (2–5yo)
(contrast HSP 4–6) |
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HSP or ITP: M > F |
HSP
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HSP or ITP: M = F |
ITP
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HSP or ITP: IgA deposits |
HSP
(contrast ITP: anti–plt Abs) |
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HSP or ITP: Anti–platelet Abs |
ITP
(contrast HSP: IgA deposits) |
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HSP or ITP: Usually preceded by viral infxn |
BOTH
HSP: viral/bact URI ITP: non–specific viral infxn |
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ITP: presents with petech/bruising and what OTHER sxs? |
NONE
(may see epistax, ICH) |
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ITP: –hepatosplenomeg? –arthralgia? |
NO
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ITP is intracranial hemorrhage common? |
NO – 0.5%
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ITP: plts <___? |
<20k
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ITP: do most pts develop significant bleed? |
NO
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What dz: viral infxn ––> PETECHIA, BRUISING ––> normal WBC, platelets <20k |
ITP
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ITP: how tx? (3) |
Steroid
IVIg Rhogham (anti–D) |
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Leukemia: see change in platelets? |
Decrease (<100k)
(BM infiltrate ––> see other cytopenias) |
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What dz: Petech/purp + bone pain + hepatosplenomeg |
Leukemia
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To percuss liver: Child in what position? |
Supine w/knees bent
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Normal liver size: –neonate –child |
Neonate: 3.5cm
Child: 2.0cm |
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Leukemia: see hepatomeg? |
YES – due infiltration
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Glycogen storage dz: see small or large liver? |
Hepatomeg
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Spleen palpable in what %: –neonates –children –adols |
Neonate: 33%
Child: 10% Adol: 2% |
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Spleen: what size is ABNORMAL? |
>2cm
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See splenomegaly?: Endocarditis |
Yes
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See splenomegaly?: SLE |
Yes
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Which storage disease: See splenomegaly |
GAUCHER
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LNs: abn if what size? |
>2cm
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Palpable LNs are considered NORMAL in what 3 areas? |
Cervical
Ax Inguinal ––> anywhere else is abn |
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Shaken Baby Syndrome: –what % die? what % poor neuro outcome? –account what % child abuse death? |
25% die, 40% poor neuro outcome
10% child abuse death |
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Shaken Baby Syndrome: Pinpoint OR dilated pupils? |
DILATED
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Shaken Baby Syndrome: Stiff or limp? |
STIFF
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Shaken Baby Syndrome: Higher mortality if <1yo or >1yo? |
<1yo
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Shaken Baby Syndrome: What TYPE of brain bleed? |
Subdural
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Subdural bleed in neonate: 2 main etios? |
1. Shaken baby
2. Vacuum NOT szs |
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Increased ICP in neonate: how affect breathing? |
See APNEA
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Bacterial mening in neonate: what % have hearing loss? |
0.2
|
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Arrythmia: common to see apnea? |
NO
See: decreased feed, irritable, lethargic |
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Suspect increased ICP if: SLOW or RAPID rr? |
SLOW
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R/o subdural bleed: what imaging 1st? |
CT ––> serial CT to monitor
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Which brain imaging best for: Shearing injury |
MRI
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Shaken Baby Syndrome: –Administer what ppx meds? –what imaging (aside from brain)? |
Anti–epileptics
Skeletal survey |
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Apnea: definition (2) |
1. No breathe >20s
2. No breath (<20s) plus brady (<100) or pallor–cyanosis |
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#1 problem in prematures |
Apnea
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What type of shock: WARM EXTREMS |
Septic
|
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Can viral infection lead to septic shock? |
Yes (via toxin production)
|
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What type of shock: ADEQUATE UOP |
Septic
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What type of shock: Bounding pulse |
Septic
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Septic shock: How tx? (2 immed management steps) |
Boluses ––> Vasopressors (E/NE/DA)
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Leads to what type of shock?: Cardiomyopathy |
Cardiogenic
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Leads to what type of shock?: Tamponade |
Cardiogenic
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Cardiogenic shock: Cool or warm extrems? |
Cool
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Cardiogenic shock: how affect UOP? |
Decrease UOP
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Leads to what type of shock?: Anaphylaxis |
Distributive shock
|
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Leads to what type of shock?: SIRS |
Distributive shock
|
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Hypoglycemia: see fever? |
No
|
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|
Encephalitis: how affect resp rate? |
NORMAL ––– tachypnea uncommon!
(contrast meningitis) |
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|
PNA in infant: expect mental status change? |
No
|
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Toxic shock syndrome: how does rash appear? |
Sunburn–like sandpaper
|
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|
What dz: Pastia's Sign |
Scarlet Fever
(linear petechia in body folds) |
|
|
Scarlet Fever: see desquam? |
Yes (5d after rash)
|
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|
Name for: Scarlet Fever ––> linear petechia in body folds |
Pastia's sign
|
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