Pediatri

Front 1

Hvordan vurderes APGAR-score?

Back 1

Front 2

Normal resp. og hjertefrekvens hos barn?

Back 2

Front 3

Når skal barn legges inn uavhengig av allmenntilstand?

Back 3

- krampeanfall 1. leveår

- feber OG petekkier

- UVI første 3 leveMÅNEDER

- feber av ukjent årsak første 3 levemåneder

- pågående oppkast/diarre med lite væskeinntak

Front 4

Hva er vanligste årsak til behandlingstrengende dehydrering hos barn?

Back 4

Akutt gastroenteritt med brekninger og oppkast.

(Akutt infeksjon i mage og tarm. Klinisk diagnose basert på oppkast, diaré, magesmerter og feber i forskjellige kombinasjoner. Agens påvises sjelden.)

Front 5

Hvorfor er det viktig å behandle barn med oppkast og diarre raskt?

Back 5

Hos spedbarn med høy feber, oppkast og vandig diaré kan væsketapet bli alvorlig i løpet av kort tid (få timer).

Klinisk alvorlig dehydrering forekommer også ved andre tilstander med oppkast, feber og/eller diaré. Det er relativt sjeldent ved febersykdommer uten oppkast og ved diarésykdommer uten oppkast hos barn som tar til seg drikke.

Barn under ett år er spesielt utsatte for hurtig dehydrering. Generelt anbefales liberal innleggelsespraksis.

Front 6

Hvilke symptomer har barn ved dehydrering?

Back 6

Barnet kan være tørst, urolig, slapt eller sløvt. Grad av dehydrering vurderes ut fra:

Forlenget kapillær fylningstid (i høyde med hjertet). Normal fylningstid er 1,5–2 sekunder.

Redusert abdominal hudturgor. Ved uttørring i vevet glir hudfolden langsomt tilbake («stående hudfold»).

Unormalt respirasjonsmønster. Dyp og/eller rask frekvens (uten patologiske lungefunn) foreligger ofte ved dehydrering (på grunn av acidose).

Flere dehydreringstegn kan være nyttige hvis de forekommer i kombinasjon, slik som innsunkne øyne, tørre munnslimhinner, kalde ekstremiteter, svak puls, fravær av tårer, økt puls, innsunken fontanell og redusert allmenntilstand. Anamnese og laboratorieundersøkelser har begrenset verdi i vurderingen.

Front 7

Hva er den vanligste årsaken til akutt nyresvikt hos barn?

Back 7

Prerenale årsaker som fører til hypovolemi og sirkulatorisk svikt. F.eks: gastroenteritt, sepsis, brannskader, blødning og nefrotisk syndrom.

Front 8

Hvilke agens fører til menigitt og hvordan spres det? Er tilstanden alvorlig?

Back 8

Meningitt er hyppigst forårsaket av virus. Ved bakteriell meningitt er Streptococcus pneumoniae (pneumokokker), Neisseria meningitidis (meningokokker) og Haemophilus influenzae vanligst. Infeksjonen spres som regel hematogent fra et primærfokus i nasofarynks eller luftveiene, men kan også skyldes direkte invasjon (otitt, fraktur, spinalvæskelekkasje). Alvorlig tilstand med høy mortalitet.

Front 9

Hvillke symptomer har barn på menigokokk?

Back 9

Kan av og til ha lite karakteristiske symptomer og funn, særlig ved alder <2 år. Nakkestivhet og utslett mangler ofte, og bildet domineres gjerne av bevissthetsreduksjon, hypotoni, irritabilitet og brekninger. I tillegg eventuelt anoreksi, diaré, dehydrering, dårlig perifer sirkulasjon og/eller kramper.

Front 10

Hvordan forløper en menigitt?

Back 10

Prodromer. Meningokokksepsis begynner ofte med prodromer i form av hoste, hodepine og sår hals.

Forverrelse. Deretter blir pasienten ofte akutt verre med høy feber, frostanfall, takykardi, takypné, leddsmerter og myalgier.

Hudmanifestasjoner. En stor andel (omtrent halvparten) av pasientene får hudmanifestasjoner, først og fremst petekkier og ekkymoser. Makulopapuløse utslett forekommer også.

Meningittsymptomer. Mangler hos mange. Pasienter med meningittsymptomer har bedre prognose enn pasienter hvor sepsis dominerer det kliniske bildet.

Sjokk. Ved fulminant meningokokksykdom utvikles sjokk og petekkiene øker raskt i utbredelse.

Front 11

Hvordan kan man oppdage petekkier?

Back 11

Petekkier blekner ikke for trykk (for eksempel med et vannglass), mens makulopapuløse utslett vanligvis lar seg avbleke.

Petekkier som utelukkende er lokalisert til ansiktet, skyldes ofte, men ikke alltid, brekninger eller hoste.

Petekkier på armene kan skyldes stase anlagt i forbindelse med venepunksjon.

Front 12

Hvorfor er menigokokkdiagnostisering vanskelig?

Back 12

Meningittdiagnostikk kan være vanskelig, særlig tidlig i sykdomsforløpet, og spesielt hos barn. Jo yngre pasienten er, desto mer atypiske kan symptomene være. I de første levemånedene debuterer meningitt ofte med unormal slapphet eller påfallende irritabilitet. Brekninger og vegring av fødeinntak er vanlig, og kan lede til at man mistolker tilstanden som gastroenteritt. I denne aldersgruppen bør en legge særlig stor vekt på foreldreobservasjoner. Ved redusert allmenntilstand, nedsatt kontaktbarhet eller hypotoni, næringsvegring og brekninger, skal barnet innlegges i sykehus for observasjon.

Front 13

Back 13

The image shown here is a 4-month-old with gangrene of her feet from meningococcemia.

Front 14

A young child presents to the local ED with a fever, rash, and lymphadenopathy. An examination of his mouth demonstrates a strawberry tongue (shown here). You suspect Kawasaki disease and tell the parents that he is most likely to suffer long-term complications in which organ system?

A. Cardiovascular

B. Neurologic

C. Gastrointestinal

D. Musculoskeletal

E. Pulmonary

Back 14

A.

Front 15

Back 15

Strawberry tounge seen in Kawasaki.

Front 16

What is Kawasaki?

Back 16

The correct answer is A. Kawasaki disease is an acute febrile vasculitis of unknown etiology. Epidemics in young children occur in the late winter and spring, with the highest incidence among individuals of Japanese descent. There are 3 distinct stages. In the acute stage (1-11 days), patients develop high fevers (> 100° F), ocular changes (conjunctivitis, anterior uveitis), perianal erythema, acral edema and erythema, oropharyngeal changes (strawberry tongue, hyperemia, fissuring), and lymphadenopathy. In the subacute stage (11-30 days), there may be persistent irritability, anorexia, conjunctival injection, thrombocytosis, acral desquamation (shown), and aneurysmal formation.

Front 17

Back 17

Acral desquamation, seen in Kawasaki

Front 18

A 3-year-old girl presents with a blistering rash on her face and body. All of the following are true statements regarding Stevens-Johnson syndrome (SJS) EXCEPT:

A. Medications, including nonsteroidal anti-inflammatory medications (NSAIDs), sulfonamides, antiepileptics, and allopurinol, are commonly accepted triggers

B. Viruses, such as herpes simplex virus, Epstein-Barr virus, enteroviruses, and influenza, are accepted triggers

C. Malignancy can be associated with SJS

D. Bacterial etiologies include mycoplasma and group A beta-hemolytic streptococcus, among others

E. Idiopathic causes are unlikely

Back 18

E.

Front 19

Back 19

A 3-year-old girl presents with a blistering rash on her face and body; Stevens-Johnson syndrome (SJS)

Front 20

Back 20

SJS (Steven-Johnsons syndrome)

Front 21

What is SJS (Steven-Johnsons syndrome)?

Back 21

SJS, often referred to as a more severe version of erythema multiforme, is a hypersensitivity reaction that occurs in response to various triggers, including infections, medications, and malignancy. Infectious agents include viruses, bacteria, fungi, and protozoa. Many medications, such as NSAIDs, antiepileptics, penicillins, sulfa drugs, TNF alpha antagonists, and some antidepressants, have also been implicated. More than a quarter of cases may be idiopathic.

Front 22

Back 22

Steven-Johnsons syndrome. may involve the mucous membranes, including the eyes and gastrointestinal tract. When more than 30% of the body surface area is involved, cases are generally referred to as toxic epidermal necrolysis. Treatment is symptomatic, including treatment of superinfection and pain control. Patients with severe cases should immediately be fluid-resuscitated and treated as burn victims. Offending agents should be removed or treated. Use of steroids is controversial. Involvement of specialists, including ophthalmologists, immunologists, and burn specialists, may be indicated. Morbidity and mortality are correlated with the percentage of body surface area involved.

Front 23

4-month-old girl presents to the ED in extremis with rapidly developing gangrene of the extremities. All of the following are true of meningococcemia EXCEPT:

A. The mortality rate is 5%-10%

B. Meningitis is present in all cases of septicemia

C. Empiric antibiotic treatment should be initiated immediately

D. Transmission is person-to-person by direct contact via respiratory droplets

E. Gangrene is caused by arterial occlusion

Image courtesy of the US Centers for Disease Control and Prevention.

Back 23

B.

Front 24

Back 24

Meningococcemia is caused by the gram-negative diplococcusNeisseria meningitides. Transmission is person-to-person via respiratory droplets, often from an asymptomatic carrier. Up to 30% of teenagers and 10% of adults carry meningococci in the upper respiratory tract. The clinical presentation is variable, with 50% of patients developing meningitis only, 10% developing septicemia only, and 40% developing both. Children with meningitis are usually febrile and ill-appearing, with symptoms of lethargy, vomiting, or nuchal rigidity. Septicemia leads to capillary leak, coagulopathy, profound acidosis, and myocardial failure. Septic emboli cause arterial occlusion in the distal extremities, as shown in this infant.

Front 25

Back 25

Meningococcemia. Patients must be closely monitored for hypotension, shock, pericarditis, organ failure, and coagulopathy, usually in an intensive care unit setting. In patients with both septicemia and meningitis, a depressed level of consciousness may be from elevated intracranial pressure or hypotension. The mortality rate, even with prompt treatment, is 5%-10%. If meningococcemia is suspected, antibiotic treatment should be initiated without waiting for confirmatory culture testing. Patients with coagulopathy and gangrene may be candidates for anticoagulation therapy.

Front 26

A child is brought into his pediatrician's office after developing a diffuse rash. His parents do not believe in vaccinations. You suspect that the child has developed measles. All of the following are true about measles EXCEPT:

A. Measles is a leading cause of death in young children worldwide

B. The classic triad is cough, coryza, and conjunctivitis

C. Koplik spots are pathognomonic white spots that appear on the buccal cheeks

D. A major early complication is acute sclerosing panencephalitis

E. Since the introduction of the measles vaccine, the annual incidence in the United States has decreased by 99%

Back 26

D.

Front 27

Back 27

Measles/meslinger.

Front 28

What is one of leading causes to death in young children worldwide (infectious disease)?

Back 28

Measles is one of the most contagious infectious diseases, with a secondary infection rate of 90% in susceptible individuals. A vaccine was introduced in 1963 which has resulted in a reduction in annual incidence in the United States of greater than 99%. However, it remains one of the leading causes of death in young children worldwide, with an estimated 197,000 deaths yearly. After exposure, the incubation period lasts for 7-14 days. Patients then develop a prodrome of high fevers, often > 104° F, with the classic triad of cough, coryza, and conjunctivitis. A couple of days later, Koplik spots develop on the buccal mucosa, appearing as white spots on an erythematous base.

Front 29

Back 29

Measles - Koplik spots develop on the buccal mucosa, appearing as white spots on an erythematous base, as shown.

Front 30

Back 30

Measles.

Within a couple of days after the Koplik spots appear, an exanthem develops which consists of blanching, erythematous macules and papules, as shown. It begins on the face at the hairline and coalesces into patches and plaques that spread cephalocaudally to the trunk and extremities. This lasts for a week before fading to hyperpigmented patches which desquamate. Vitamin A deficiency has been associated with a worse prognosis, including blindness, so all children diagnosed with measles receive supplementation. Care is otherwise supportive with adequate hydration. Subacute sclerosing panencephalitis is a late, long-term complication caused by persistent infection of immune resistant measles.

Front 31

6-year-old boy presents with swelling on both sides of his face and complains of pain while chewing. He has a fever of 101.1° F. He has not been vaccinated for mumps. All of the following are true statements about mumps EXCEPT:

A. It is generally a benign condition, with the majority of those infected being asymptomatic

B. Viral encephalitis is a rare but serious complication

C. Orchitis and infertility are rare complications and are less likely to occur in children

D. Mumps is not associated with hearing loss

E. Complications of mumps include meningitis, pancreatitis, oophoritis, and miscarriage

Back 31

D.

Front 32

Back 32

Mumps/Kusma.

Front 33

Back 33

Mumps/Kusma is caused by a virus that can cause inflammation of the parotid glands. It is generally a benign condition, with the majority of those infected being asymptomatic. However, certain rare but serious complications can occur. Prior to immunization against mumps, it was a major cause of hearing loss in children. Rarely it causes viral meningitis, encephalitis, and pancreatitis. Orchitis does not usually occur in children but can occur in teens and young adults. Infertility can occur in those with orchitis. Miscarriage can occur in women with mumps in the first trimester. Two recent outbreaks occurred, in 2006 and 2009, highlighting the importance of vaccination.

Front 34

11-year-old girl presents with raised violaceous plaques on her legs and arms that developed over the last few days. She has had a temperature of 100-101° F at home but no other complaints. Her current temperature is 100.2° F. The rest of her exam is normal. You conclude that she has Henoch-Schonlein purpura (HSP). Which of the following tests are most appropriate to perform at this point?

A. CBC, lumbar puncture

B. CBC, electrolytes, stool for occult blood, urinalysis

C. CBC, electrolytes, stool for occult blood, renal ultrasound

D. CBC, head CT, lumbar puncture, abdominal ultrasound

E. CBC, abdominal ultrasound

Back 34

B.

Front 35

Back 35

Henoch-Schonlein purpura.

Front 36

Back 36

Henoch-Schönleins purpura. The images shown are purpuric lesions. In this case of a healthy-appearing child with this history and physical examination, HSP is a reasonable diagnosis. HSP is a vasculitis that can affect the skin, joints, gastrointestinal tract, and kidneys. In a well-appearing child, HSP can be managed on an outpatient basis. It is helpful to check blood pressure, urine, and electrolytes to look for a glomerulonephritis. Urinalysis and blood pressure may be followed for several months to monitor kidney function. A fecal occult blood test can help rule out significant gut involvement, especially in children with pain. Intussusception is the most serious complication of HSP; if it is suspected, the child should be admitted and monitored.

Front 37

Back 37

Platelet count is generally normal in Henoch-Schönleins Purpura, helping to differentiate it from idiopathic thrombocytopenic purpura (ITP), which has low platelets. ITP presents with petechiae, bruising (as shown), or bleeding, often in areas of trauma. If counts are sufficiently low, there is a risk for intracranial bleed. A consult with hematology can help determine appropriate management in case of uncertainty.

Front 38

Developmental limit ages?

Back 38

•2 months: response smiling
•3 months: good eye contact
•5 months: reaches for objects
•10 months: sits unsupported

•12 months: Pincer grip
•18 months: walks unsupported
•18 months : says single words with meaning
•20 months: speaks in phrases

Front 39

Hva kan føre til gult spedbarn eldre enn 14 dager (prolongert ikterus)?

Back 39

Ukonjugert hyperbilirubinemi

OBS fare for kjerneikterus.

ELLER

Konjugert hyperbilirubinemi

Indikerer nesten alltid leversykdom.

Front 40

Hva forårsaker ukonjugert hyperbilirubinemi?

Back 40

Ukonjugert hyperbilirubinemi

Kan forårsakes av: infeksjon, hemolyse, hypoglykemi, hypotyreose, medikamenter, pre­maturitet, enzym defekter, morsmelk.
OBS fare for kjerneikterus.

Front 41

Hvilke kliniske funn har man ved konjugert hyperbilitubinemi?

Back 41

Dette er en ø-hjelp situasjon, til tross for at

Barnet ofte tilsynelatende er i god allmenntilstand og har «farget» avføring og «lys» urin!

Front 42

Hva indikerer konjugert hyperbilirubinemi (årsak, organ)? Hva må man utelukke?

Back 42

Konjugert hyperbilirubinemi

Indikerer nesten alltid leversykdom: «Neonatalt kolestase syndrom/neonatalt hepatitt syndrom».
Fellesnevneren er ikterus og konjugert hyperbilirubinemi, ofte observeres også andre uspesifikke kli­niske (hepatomegali, avfarget avføring, mørk urin) og laboratoriemessige tegn til leverdysfunksjon/ inflammasjon.

Man må utelukke/bekrefte kirurgisk korrigerbare tilstander: ekstrahepatisk gallegangsatresi, choledocus cyste. Best resultat ved tidlig kirurgi.

Front 43

Diagnose og klassifisering av CP baserer seg på en klinisk vurdering, hvordan beskrives det?

Back 43

1. Hvilken bevegelsesforstyrrelse som dominerer – Spastisk (70–85 %), - Dyskinetisk (10–20 %) - Ataktisk (< 10 %)
2. Distrubisjon – unilateral eller bilateral

Front 44

Hva er den vanligste formen for CP?

Back 44

Spastisk CP

Front 45

Den vanligste formen Spasitsk CP kan topografisk deles inn i 3 undergrupper. Det vil si hvilke kroppsdeler som er affisert. Hva kalles disse undergruppene?

Back 45

- Spastisk diplegi er den vanligste formen og betyr at alle ekstremiteter er involvert, men bena betydelig mer enn armene.

- ved hemiplegi er bevegelseshemningen enten i høyre eller venstre kroppshalvdel. Armene er ofte mer affisert enn bena og særlig perifert.

- Ved kvadriplegi alle ekstremiteter er involvert, men som hovedregel mest i armene. I tillegg er det affeksjon av ansikt og munnmotorikk. Microcefali er vanlig og bevegelseshemningen er sjelden barnets største problem for videre utvikling.

Front 46

Hva er symptomer på akutt nyresvikt?

Back 46

Oligouri