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Terms in this set (481)
What is the MC causative organism of osteomyelitis in children?
Staph aureus (children with sickle cell disease are more prone to Salmonella ostomyelitis, but S aureus is still more common)
18 mo old presents refusing to walk. She has marked tenderness over her distal L femur & temp of 101.7, ESR of 77 mm/hr, and WBC of 18.5. XRs are normal. What should be considered?
osteomyelitis (periosteal and lytic changes may not be seen until substantial bone destruction has occurred)
_____________ is an organism that can cause osteomyelitis and should be considered in children who attend day care.
What is the MC site of osteomyelitis in children?
rapidly growing end (metaphysis) of long bones
Consider _____________ in any child with decreased use of a limb and fever.
What can be used for initial treatment of pediatric osteomyelitis?
oxacillin (penicillinase-resistant penicillin) + cefotaxime (cephalosporin)
14 yo presents with R knee pain x 2 days. Temp is 100.7, pulse 102. Knee is mildly swollen and tender on exam, held in flexion. What should you do?
aspirate joint, consider septic arthritis
What is the MC causative organism of monoarticular septic arthritis?
What is the MC causative organism of polyarticular septic arthritis?
_____________ is not necessary for diagnosis of septic arthritis.
What is the MC cause of hip pain in childhood?
What is the MC mimic of septic arthritis?
16 yo boy presents with anterior knee pain. On exam, there is tenderness over the tibial tuberosity. What is the likely dx and trx?
Osgood-Schlatter disease, activity restriction
What is Legg-Calve-Perthes disease?
avascular necrosis of the femoral head
6 yo boy presents c/o hip & knee pain. He has been limping. On exam, he is unable to abduct or internally rotate his hip. What should be considered? How is it diagnosed?
avascular necrosis of the femoral head (Legg-Calve-Perthes disease); XR
What is the MC cause of limping and acute hip pain in pts 3-10? What should be r/o?
toxic synovitis; r/o avascular necrosis of the femoral head (Legg-Calve-Perthes disease)
What is the trx for avascular necrosis of the femoral head (Legg-Calve-Perthes disease)?
pediatric orthopedic consult, rest + NSAIDs, surgery for 6-10 yo with large areas of necrosis
14 yo boy c/o pain in L anterior thigh x 2 mo. On exam, there is limited passive flexion and internal rotation of the hip. What is the most likely dx?
slipped capital femoral epiphysis (SCFE)
What is the MC orthopedic hip disorder in adolescents?
slipped capital femoral epiphysis (SCFE)
How is SCFE diagnosed?
AP and frog-leg lateral XR of both hips, ice cream scoop falling off its cone (frog-leg lateral shows subtle displacement more clearly)
What is the treatment for SCFE?
ortho consult, non-weight bearing, internal fixation
When should the anterior fontanelle close?
When should the posterior fontanelle close?
A newborn with delayed stool (> 48 h) may have what?
Hirschsprung disease, cystic fibrosis, imperforate anus
What may cause vaginal leukorrhea (bloody discharge) in a newborn?
_______________ maneuver reduces the hip in a newborn with congenital hip dysplasia.
Ortolani - abduction of hip with anterior (upward) force
_______________ maneuver dislocates the hip in a newborn with congenital hip dysplasia.
Barlow - adduction of hip with posterior (backward) force
How can congenital hip dysplasia be treated?
Pavlik harness (or casting)
What is used to close a patent ductus arteriosus?
prostaglandin inhibitors -
or Ibuprofen (prostaglandins keep the ductus arteriosus patent)
Why are Ibuprofen and Indomethacin (prostaglandin inhibitors) avoided in pregnancy?
would close the ductus arteriosus (important to fetal circulation, allows nutrient/oxygen rich blood to travel from pulmonary artery to aortic arch, bypassing the lungs)
Name some characteristics that would indicate a murmur is "innocent."
soft, not a/w sx, position dependent, systolic (systolic murmurs ~can~ be pathologic, but
diastolic murmurs are almost always pathologic
What is the MC type of innocent murmur?
Name the congenital cyanotic heart diseases.
Truncus arteriosus (1 vessel instead of 2)
Transposition of great arteries (2 vessels switched)
Tricuspid atresia (3 = tri)
Tetralogy of Fallot (4 = tetra)
Total anomalous pulmonary venous return (5 vessels involved - all 4 pulmonary veins connect to SVC instead of L atrium)
Hypoplastic left heart syndrome (mitral valve &/or aortic valve atresia)
What is truncus arteriosus?
aorta & pulmonary artery are 1 vessel
What is transposition of great arteries?
aorta & pulmonary artery are switched
What is tricuspid atresia?
absence of tricuspid valve (leads to hypoplastic RV; ASD & VSD must be present for blood to flow out of R atrium)
What is Tetralogy of Fallot?
Interventricular septal defect
Hypertrophy of R ventricle
How would VSD sound on exam?
loud, high-pitched holosystolic murmur at the lower LSB
Larger VSD shunts are repaired by age 2 to prevent _______________.
There is initially _______________ shunting with ventricular septal defect (VSD).
left to right (pressure in LV > RV, may switch with Eisenmenger's syndrome)
What is Eisenmenger's syndrome?
reversal of a left-to-right shunt due to progressive pulmonary hypertension
When would surgery be considered for a pt with VSD?
large, symptomatic infant, uncontrolled CHF, growth delay, recurrent respiratory infections
Pt has a continuous machinery murmur with bounding pulses (wide pulse pressure). What is the most likely dx?
patent ductus arteriosus
Pt has a systolic ejection murmur with a widely fixed, split S2. What is the most likely dx?
atrial septal defect
What is the trx for atrial septal defect?
will likely spontaneously close by 1 year, surgery if symptomatic (usually 2-4 yrs)
Pediatric pt presents with hypertension, BLE claudication, and a systolic murmur. SBP in upper extremities greater than LE. What is the most likely dx?
coarctation of the aorta
70% of patients with _______________ also have a bicuspid aortic valve.
coarctation of the aorta
What is the gold standard for diagnosing coarctation of the aorta?
What is a "Tet spell" & when is it seen?
cyanosis relieved with squatting or bringing infant's knees to chest, seen with Tetralogy of Fallot
What symptomatology is consistent with Kawasaki disease?
(warm + CREAM) pediatric pt with fever lasting 5+ days with four of the following:
Conjunctivitis: bilateral & non-exudative (+/- photophobia)
Rash: polymorphous (erythematous, morbiliform, or macular)
Extremity (peripheral) changes: desquamation (esp perineum), edema, erythema of the palms & soles, induration of hands & feet, Beau's lines (transverse nail grooves), arthritis
Adenopathy: cervical LAD
Mucous membrane: pharyngeal erythema, lip swelling & fissures, strawberry tongue
What is the MC acquired heart disease in children?
What are the major potential complications of Kawasaki disease?
coronary aneurysms, pericardial effusion, CHF
What is Kawasaki disease?
referred to as mucocutaneous lymph node syndrome, acute vasculitis of medium & small vessels including coronary arteries
What initial study is done at diagnosis of Kawasaki disease?
echo (to establish baseline and evaluate for early coronary aneurysms)
What is the treatment for Kawasaki disease?
- IVIG (usually 1 dose of 2 g/kg over 10-12 hr, reduces incidence of coronary artery dilation)
- high (80-100 mg/kg/day) or low (3-5 mg/kg/day) dose ASA depending on presence of coronary artery abnormality
- consult pediatric cardiology with coronary artery abnormality
Name some s/sx of Kawasaki disease.
sterile pyuria, aseptic meningitis, thrombocytosis, desquamation of fingers & toes, elevated ESR or CRP
What is treatment for hypertrophic obstructive cardiomyopathy?
moderate restriction of physical activity, BB or CCB (to improve filling), endocarditis prophylaxis
What is seen on EKG with hypertrophic obstructive cardiomyopathy?
LVH, left atrial enlargement, large Q wave (echo may show asymmetrical septal hypertrophy, outflow obstruction)
What is the age range of a neonate?
birth - 28 days
What is the age range of an infant?
1 mo - 1 year
What is the age range of a toddler?
1 - 3 years
What is the age range of a preschooler?
3 - 6 years
What is the age range of an adolescent?
7 - 21 years
What is the MC cause of cough in school-aged children?
In an asthmatic patient, airway obstruction could result in ______________ or ______________.
What is the classic trilogy of asthma?
bronchospasm, mucus production, inflammation and edema of the airway mucosa
Name some goals of asthma treatment.
improve bronchodilation, avoid allergens, dec inflammation, educate patient
What is Samter's triad?
asthma + nasal polyps + ASA/NSAID allergy
What is first line treatment for acute asthma sx?
albuterol (less $ than levalbuterol) (both are SABAs)
When would Ipratropium bromide (short-acting muscarinic antagonist) be used to treat asthma?
in addition to albuterol (duoneb, good for moderate-severe exacerbation in ED) or as an alternative (when pt does not tolerate SABA)
What is the role of oral corticosteroids in asthma treatment?
exacerbations in addition to SABA, long term for pts requiring step 5 care (typically given as a burst - prednisolone 1-2 mg/kg/day x 3-5 days)
What "control" medications can be used in asthma?
ICS: beclomethasone proprionate (QVAR Redihaler), budesonide, flunisolide, fluticasone propionate
What are some important counseling points for inhaled corticosteroids (ICS)?
rinse mouth after every use, take even when you don't have sx
What is Flovent?
ICS (fluticasone propionate)
What is Pulmicort?
What is QVAR?
ICS (beclomethasone dipropionate)
What is Atrovent?
SAMA (Ipratropium bromide)
What is ProAir?
What is Proventil?
What is Ventolin?
What is Xopenex?
______________ are NEVER used as monotherapy for prevention or as a substitute for corticosteroids in asthma patients, nor should they be initiated in pts with significantly worsening or acutely deteriorating asthma.
What role does a LABA play in asthma treatment?
long-term prevention in addition to ICS
Name some LABAs.
salmeterol, formoterol nebulizer
What is Advair?
ICS/LABA combo (fluticasone/salmeterol)
What is Symbicort?
ICS/LABA combo (budesonide/formoterol)
What is the atopic march?
asthma, atopic dermatitis (eczema), allergic rhinitis
What is the classic triad of asthma?
dyspnea, wheezing, cough (esp at night)
What would be some CI to giving a pt with an acute asthma exacerbation cortiocosteroids?
active varicella, herpes infection
Why would mag sulfate be given to a patient with an acute asthma exacerbation?
bronchodilation, relaxes smooth muscle
Dehydration may be present in status asthmaticus, but overhydration should be avoided due to r/o ______________.
syndrome of inappropriate antidiuretic hormone secretion (SIADH)
2 yo male presents to ED with h/o choking/gagging episode, followed by a coughing spell. Wheezes present on exam. RR is 24 with mild intercostal retractions. What is the most likely dx?
foreign body aspiration
Where is the narrowest portion of the pediatric airway?
What is the MC aspirated foreign body?
What is the MC aspirated foreign body resulting in death?
Name some potential complications of FB aspiration if object is not removed.
pneumonitis/PNA, abscess, bronchiectasis, pulmonary hemorrhage, erosion, perforation
Hyperresonant percussion of lung fields indicates ______________.
Dull percussion of lung fields indicates ______________.
Foreign bodies most commonly aspirate in the ______________ main stem.
Why is ASA avoided in pediatric patients?
r/o Reye''s syndrome
Pt presents with sudden onset of fever, chills, HA, malaise, myalgias, & non-productive cough. What dx should be suspected?
Name some potential complications of influenza.
OM, PNA, myositis, myocarditis
What is the trx for influenza?
fluids, rest, acetaminophen for healthy children; Oseltamavir during pregnancy
Influenza can be severe in children with what chronic conditions?
congenital heart disease, bronchopulmonary dysplasia, asthma, cystic fibrosis, neuromuscular disease
A "barking cough" is classic of ______________.
What is the MC cause of croup?
parainfluenza virus type 1
What is another name for croup?
______________ is the MC cause of stridor in a febrile child.
Pt with stridor and distress at home but calm and free of stridor in the ED, think ______________.
What imaging may be done to help identify suspected croup?
frontal cervical XR - steeple sign
What is the treatment for croup?
mild (no stridor at rest, no resp distress): cool humidified air mist, hydration, consider dexamethasone
moderate (stridor at rest with mild-moderate retractions): dexamethasone PO or IM, supportive treatment, nebulized epi
severe (stridor at rest w/ marked retractions): dexamethasone, nebulized epi, admission
What is the MC serious respiratory infection in children < 2?
What is the MC cause of acute bronchiolitis?
respiratory syncytial virus (RSV) (less common: adenovirus, parainfluenza 3, influenza, human metapneumovirus (hMPV))
What is occurring physiologically in a pt with bronchiolitis?
inflammatory obstruction (edema and mucus) of the bronchioles secondary to viral infection
What is the treatment for bronchiolitis?
supportive: humidified O2, IVF, acetaminophen or ibuprofen for fever
What is the MC cause of neonatal jaundice?
What is the main potential complication of hyperbilirubinemia?
kernicterus - bilirubin neurotoxicity
How does phototherapy work for hyperbilirubinemia?
converts bilirubin to photoisomer that is excreted in urine
How does jaundice progress in newborns?
head to toe
(head & neck - 4-8; upper trunk - 5-12; lower trunk & thighs - 8-16; arms & lower legs - 11-18; palms and soles - > 15)
When are infants at risk for kernicterus?
bili > 20-25
What manifestations may occur with kernicterus?
cerebral dysfunction, encephalopathy, seizures, lethargy, irritability, hearing loss, mental developmental disorders
_______________ - "attempted" suicide done for attention without intent for death
Cystic fibrosis is an inherited multisystem disorder resulting in _______________, _______________, and _______________.
chronic lung disease, exocrine pancreatic insufficiency, failure to thrive
What is the MC lethal inherited disease of Caucasians?
What is cystic fibrosis?
disease of exocrine glands resulting in vicious secretions, which causes chronic respiratory infections, pancreatic insufficiency, inc electrolytes in sweat
3 yo presents with constant productive cough and loose stools. He has had 6 episodes of PNA with Pseudomonas isolated from sputum. 20th percentile for growth. What is the most likely dx?
Name the features of CF.
Failure to thrive
Electrolytes inc in sweat
Absence of vas
99% of cases of meconium ileus are due to _______________.
What does the diagnosis of epilepsy require?
2+ unprovoked seizures
Name some potential etiologies of a seizure.
Infection (meningitis, encephalitis)
Trauma (TBI, brain bleed)
Autoimmune (SLE, etc)
Ingestion & withdrawal (BZD or ETOH withdrawal)
_______________ - type of seizure in which there is a sudden brief discontinuation of activity and unresponsiveness
_______________ - type of seizure in which there is bilateral symmetric tonic contraction, then bilateral clonic contractions
_______________ - type of seizure in which there is sustained muscle contractions for seconds to minutes
_______________ - type of seizure in which there is repetitive, rhythmic myoclonus at 2-3 Hz
_______________ - type of seizure in which there is sudden, brief (< 100 ms) involuntary contraction of muscles or group of muscles
_______________ - type of seizure in which there is a sudden, brief, 1-2 sec dec in tone without preceding myoclonic or tonic event
What is a big distinguishing factor between simple partial and complex partial seizures?
consciousness fully maintained in simple partial
What is the MC sx of simple partial seizures?
The presence of an aura always indicates _______________.
a focal onset of seizure
What is a "grand mal" seizure?
generalized tonic-clonic seizure; pt suddenly loses consciousness, eyes roll back, entire musculature undergoes tonic contractions (rarely will arrest breathing)
What is the MC seizure disorder during childhood?
simple febrile seizure
What should you do if you are present during a tonic-clonic seizure?
keep track of duration, place patient between prone and lateral decubitus to allow tongue and secretions to fall forward, hyperextend neck and jaw to enhance breathing, loosen any tight clothing or jewelry around neck,
do not force open mouth or teeth
A febrile seizure lasting > 15 min suggests _______________.
organic cause such as meningitis or toxin exposure
You intubate a patient, who then stops seizing. What is something you should be concerned for?
paralytic stopped convulsions and pt is still seizing
What is the best way to determine if LOC was due to seizure or syncope?
A child is having trouble in school because he keeps losing focus and does not always respond to the teacher. What is something that should be considered other than ADHD, and what is the treatment?
absence seizures, Ethosuxamide (Zarontin)
What is first line treatment for absence (petit mal) seizures?
What can be used to manage grand mal (generalized tonic clonic) seizures?
Valproic acid (Depakene/Depakote), Phenytoin (Dilantin), Carabamazepine (Tegretol), Lamotrigine (Lamictal)
What is a caution/SE of Ethosuxamide (Zarontin)?
caution in renal or hepatic failure
What is a caution/SE of Valproic acid (Depakene/Depakote)?
SE: pancreatitis, hepatotoxicity; caution in hepatic disorders
What is a caution/SE of Lamotrigine (Lamictal)?
SE: Steven Johnson Syndrome (SJS)
What is the treatment for status epilepticus in children?
2) thiamine (vitamin B1, 100 mg IV) + D50 if hypoglycemic
3) BZD (Ativan 0.1 mg/kg, Midazolam 5 mg IM < 40 kg, 10 mg IM 40+ kg) several rounds
4) Fosphenytoin (20 mg PE/kg IV) or Keppra (60 mg/kg)
What is a caution/SE of Phenytoin (Dilantin)?
erythema multiforme or SJS, gingival hyperplasia, hirsutism, arrhythmias (esp with rapid administration) (MONITOR DRUG LEVELS)
What is a caution/SE of Carbamazepine (Tegretol)?
hyponatremia causing SIADH, SJS
How can you differentiate seizures from pseudoseizures?
How is meningitis definitively diagnosed? What would indicate acute bacterial meningitis?
CT Head before CSF exam (LP); 100-10,000 PMN (neutrophils), dec glucose (< 45), inc total protein, inc CSF pressure (*Do not wait for LP results to start empirical abx)
What is the MC cause of acute bacterial meningitis < 1 mo? What is the empiric management?
GBS (Strep agalactiae), Ampicillin + Cefotaxime
What is the MC cause of acute bacterial meningitis 1 mo - 18 yo? What is the empiric management?
N meningitidis (a/w petechial rash); Ceftriaxone + Vancomycin
What is the MC cause of acute bacterial meningitis 18-50 yo? What is the empiric management?
S pneumo (secondly N meningitidis); Ceftriaxone + Vancomycin
What is the MC cause of acute bacterial meningitis 50 + yo? What is the empiric management?
S pneumo, Listeria monocytogenes; Ampicillin + Ceftriaxone +/- Vancomycin
With suspected meningitis, if _______________, then viral meningitis is most likely. If _______________, then bacterial is most likely.
viral: normoglycemic; bacterial: WBC predominantly neutrophils
_______________ - viral infection of the MENINGES
_______________ - viral infection of the BRAIN PARENCHYMA
viral meningitis - meninges; encephalitis - brain parenchyma
What is seen on LP in a pt with viral meningitis?
normal glucose, lymphocytosis
What is the MC cause of viral meningitis?
enterovirus family (echovirus, Coxsackie)
What is the MC cause of encephalitis?
_______________ is given for HSV encephalitis or if no identifiable cause of meningitis.
Valacyclovir (+/- immunoglobulin if immunocompromised)
What clinical manifestation may help differentiate viral meningitis from encephalitis?
encephalitis: abnormal cerebral function, poss sensory/motor deficits or speech/movement disorders (often nl with meningitis; LP results can help differentiate acute bacterial meningitis from these two dx)
What are the physiologic consequences of anemia?
less oxygen transport, dec blood volume, inc cardiac output
When working up anemia, what does an inc reticulocyte count indicate?
brisk bone marrow response to hemolysis or blood loss
When working up anemia, what does a dec reticulocyte count indicate?
deficient RBC production
Name some intrinsic (hereditary) causes of RBC destruction (hemolysis).
G6Pd deficiency, sickle cell, thalassemia, hereditary spherocytosis
Name some extrinsic (acquired) causes of RBC destruction (hemolysis).
autoimmune hemolytic anemia, hypersplenism, DIC/TTP/HUS, paroxysmal nocturnal hematuria
Name some microcytic anemias.
Fe deficiency, lead, thalassemia, early anemia of chronic dz
Name some normocytic anemias.
anemia of chronic dz: renal, mixed anemia, endocrine, dilutional, early Fe deficiency
Name some macrocytic anemias.
B12 deficiency, folate deficiency
B12 deficiency affects what biological process?
Diseases affecting the _______________ may cause B12 deficiency.
terminal ileus (Crohn's, Celiac)
Why does pernicious anemia lead to a B12 deficiency?
destruction of parietal cells, thus stomach acid is not produced to bind B12 to intrinsic factor for absorption in the terminal ileum
Hypersegmented neutrophils are indicative of _______________.
B12 or folate deficiency
What do you need to watch for with IM vitamin B12 & why?
hypokalemia - B12 replacement leads to reticulocytosis with new cells taking up large amounts of K+
Which macrocytic anemia will present with neurologic abnormalities?
B12 deficiency (folate does not have neuro sx)
What will happen if a B12 deficiency is treated with folate?
B12 deficiency will correct but neuro sx will worsen
What is the MC cause of iron deficiency anemia?
chronic blood loss (excessive menstruation, etc)
Name some potential PEx findings in iron deficiency anemia.
pagophagia (ice craving), pica, angular cheilitis, koilonychia
What is Plummer-Vinson syndrome?
dysphagia + esophageal web + atrophic gastritis + Fe deficiency
How is iron deficiency anemia diagnosed?
dec ferritin, inc TIBC, dec serum Fe, inc RDW, dec transferrin saturation
Iron deficiency anemia and anemia of chronic dz both have decreased serum Fe. How do you distinguish between the two?
IDA will have dec ferritin & inc TIBC (Fe deficient so no Fe in storage thus inc binding capacity), whereas anemia of chronic dz will have inc ferritin and dec TIBC (Fe pulled into storage as defense mechanism as invasive organisms rely on Fe)
Why does reticulocytosis occur with hemolytic anemias?
bone marrow trying to replenish depleted RBCs
Why does inc LDH occur with hemolytic anemias?
LDH is an enzyme found within RBCs, so hemolysis leads to inc serum LDH
Elevated indirect bilirubin may lead to ______________, whereas elevated direct bilirubin may lead to ______________.
jaundice, dark urine
Why does dec haptoglobin occur with hemolytic anemias?
inc RBC destruction leads to inc free hgb, and haptoglobin binds to free hgb (to reduce its oxidative toxicity)
What are schistocytes?
fragmented RBCs resulting from inc RBC destruction in the spleen, liver, or small blood vessels
Name some medications that may cause a folate deficiency.
Methotrexate, Bactrim, Phenytoin
Vitamin ____ increases Fe absorption.
How can IDA be treated & what are common SE?
Ferrous sulfate 325 mg PO daily; GI SE such as N/V, constipation, cramps, so start with low dose & gradually inc it (reticulocyte count should increase w/in 7 days)
What does lead poisoning do physiologically?
causes cell death, shortens lifespan of RBCs, inhibits multiple enzymes needed for heme synthesis
How is lead poisoning diagnosed?
inc serum lead & serum Fe; peripheral smear shows microcytic, hypochromic anemia with basophilic stippling (dots of denatured RNA) & ringed sideroblasts in bone marrow (iron accumulation in mitochondria d/t failure of incorporation of Fe into hgb)
How is lead poisoning treated?
remove source of lead, chelation therapy if severe
How may pts with lead poisoning present?
abdominal pain with constipation, neuro sx (ataxia, fatigue, learning disability, coma, shock), anemia sx, metabolic acidosis (a-sx is possible)
What may be seen on XR with a lead poisoning?
lead lines - linear hyperdensities at metaphyseal plates
What is the MC inherited bleeding disorder?
von Willebrand disease
Platelet disorders (ITP, TTP, HUS, DIC) affect ______________.
Will platelet disorders have prolonged PT & PTT?
What sx are seen with platelet disorders?
petechiae, mucocutaneous bleeding (oral, GI, menorrhagia)
Clotting disorders (hemophilia, DIC, vWD) affect ______________.
Will clotting disorders have prolonged PT & PTT?
yes (disease affecting extrinsic pathway will prolong PT; disease affecting intrinsic pathway will prolong PTT)
What sx are seen with clotting disorders?
deep delayed bleeding such as hemarthrosis
What may cause a prolonged PTT?
heparin, DIC, vWD, hemophilia A & B, antiphospholipid antibodies
What is the antidote for a heparin overdose?
What may cause a prolonged PT?
warfarin therapy, vitamin K deficiency, DIC
What is the antidote for a warfarin overdose?
What is the thrombotic thrombocytopenic purpura (TTP) pentad?
thombocytopenia (bruising, purpura, mucocutaneous bleeding)
microangiopathic hemolytic anemia
neuro sx (HA, AMS, CVA)
What is the treatment of choice for thrombotic thrombocytopenic purpura (TTP)?
What is the hemolytic uremic syndrome (HUS) triad?
microangiopathic hemolytic anemia
kidney failure (uremia, more common in HUS than TTP)
Hemolytic uremic syndrome (HUS) is usually preceded by ______________.
enterohemorrhagic E coli, Shigella, or Salmonella gastroenteritis
What is the treament for HUS?
observation in most, plasmapharesis if severe (
Abx will worsen condition
What is the MC cause of DIC?
gram neg sepsis (other 2 MC are malignancy and obstetric)
Pt presents acutely ill with widespread hemorrhage (mouth, nose, extensive bruising), gangrene, and thrombosis. What is the most likely dx?
disseminated intravascular coagulation (DIC)
What is the treatment for DIC?
treat underlying cause, FFP for severe bleeding
When is acute idiopathic (autoimmune) thrombocytopenic purpura (ITP) most commonly seen?
in children after a viral infection
When is chronic idiopathic (autoimmune) thrombocytopenic purpura (ITP) most commonly seen?
women < 40
How is ITP diagnosed?
isolated thrombocytopenia with normal coag tests
What is the treatment for ITP?
children: observation +/- IVIG
adults: corticosteroids (blunts immune response) > IVIG > splenectomy if refractory
What is the MC type of hemophilia?
hemophilia A (factor VIII deficiency)
How is hemophilia A diagnosed?
low factor VIII, prolonged PTT (& normal platelet levels)
How do you differentiate between hemophilia A & B clinically?
Which type of hemophilia occurs almost exclusively in males?
What is the treatment for hemophilia A?
factor VIII infusion, desmopressin
What is the treatment for hemophilia B?
factor IX infusion (desmopressin not useful)
How are hemophilia A & B distinguished clinically?
How does a mixing study help identify causes of bleeding issues?
distinguishes factor deficiencies (vWD, hemophilias) from factor inhibitors (lupus anticoagulant, Ab vs Factor VIII) (If PTT does not correct with mixing study--presence of factor inhibitors)
Name 3 clinical indicators of acute liver injury/failure following a Tylenol overdose.
AMS, hypoglycemia, coagulopathies
What causes bleeding in von Willebrand disease?
ineffective platelet adhesion d/t deficient/defective vW factor (platelet aggregation is normal, only platelet adhesion is affected)
_______________ are common in vWD but rare in hemophilia.
How is von Willebrand disease diagnosed?
dec vWF levels, +/- prolonged PTT,
dec Ristocetin activity gold standard
With a Tylenol overdose, what is the risk of giving IV N-acetyl-cysteine over PO?
inc r/o anaphylaxis
What type of lymphoma is a/w the Epstein-Barr virus?
In what disease would ETOH induce lymph node pain?
What would indicate a pt with Hodgkin lymphoma has advanced disease?
systemic "B" sx: Pel-Ebstein fever (cyclical fever that inc & dec over a period of 1-2 weeks, night sweats), wt loss, anemia, pruritis
An excisional bx of a lymph nodes shows large cells with bilobar or multilobar nucleus ("owl eye appearance") with inclusions in the nuclei. What is the dx?
Hodgkin lymphoma - Reed-Sternberg cells pathognomic
Reed-Sternberg cells are pathognomic for _______________.
How is Hodgkin lymphoma diagnosed?
Reed-Sternberg cells on excisional bx, mediastinal LAD followed by PET/CT
Which type of lymphoma is highly curable?
_______________ - type of lymphoma that often presents with abdominal pain, jaw involvement; histology shows "starry sky" appearance
Burkitt lymphoma (NHL type)
Which type of lymphoma oftentimes has extranodal sites (GI, skin, CNS)?
non Hodgkin lymphoma
Which type of lymphoma is MC in upper body lymph nodes (neck, axilla, shoulder, abdomen)?
What is the MC childhood malignancy?
Acute lymphocytic leukemia (ALL)
What is the MC sx of acute lymphocytic leukemia (ALL)?
Acute lymphocytic leukemia (ALL) is highly responsive to _______________.
Name 2 differentials that should be excluded prior to diagnosing croup.
epiglottitis, foreign body aspiration
What is the MC cause and source of viral conjunctivitis?
adenovirus, swimming pool
Pt presents with watery discharge from eye with preauricular LAD on exam. Punctate staining present with slit lamp. What is the dx and trx?
viral conjunctivitis, supportive (cool compresses, artificial tears)
Pt presents with bilateral conjunctival erythema with cobblestone mucosa appearance to eyelid and chemosis (eyelid swelling). What is the dx and trx?
allergic conjunctivitis, olpatadine or pherniramine/naphazoline (topical antihistamines)
What is the MC cause of bacterial conjunctivitis?
S aureus (also Strep pneumo, contact lens think Pseudomonas)
Pt presents with purulent discharge from eye and lid crusting. What is the most likely dx and trx?
bacterial conjunctivitis, topical erythromycin (or moxifloxacin for Pseudomonas)
Pt presents with decreased vision, pain with ocular movement, proptosis (bulging eye), and eyelid erythema and edema. Reports sinus infection 1-2 wks ago. What should you order? Most likely dx? Trx?
high resolution CT (infection of fat and ocular muscles), orbital (septal) cellulitis, IV Vancomycin or Clindamycin (Amoxicillin if preseptal)
How is preseptal cellulitis differentiated from septal (orbital) cellulitis?
Preseptal will have no visual changes and no pain with ocular movement (infection of eyelid and periocular tissue)
_______________ - convergent strabismus, deviated inward
_______________ - divergent strabismus, deviated outward
How is strabismus tested for on exam?
Hirschberg corneal light reflex (screening), cover-uncover test (determine angle)
How is strabismus treated?
patch therapy (nl eye covered to strengthen and stimulate affected eye) or eyeglasses; corrective surgery is severe or unresponsive to conservative therapy
What may occur if strabismus is not treated prior to 2 years of age?
ambylopia - dec visual acuity not correctable by refractive means
Avoid giving _______________ with chicken pox due to risk of causing disseminated infection.
How do pts with HSV present?
prodomal burning, paresthesias, tingling that develops into a vesicular rash on an erythematous base
Slit lamp exam reveals dendritic ulcers. What is the diagnosis?
What is the most sensitive and specific test for HSV?
What is given for HSV?
Acyclovir (IV for encephalitis)
A "dew drops on a rose petal" rash in
refers to _______________.
varicella zoster virus (chicken pox)
_______________ - shingles involving the first division of the trigeminal nerve (V)
herpes zoster ophthalmicus
What is Ramsay-Hunt syndrome?
herpes zoster of the facial nerve; otalgia, lesions on the ear, auditory canal, & TM, facial palsy, auditory sx
_______________ - pain lasting > 3 mo, hyperesthesias, or decreased sensation; related to HZV
How is shingles (HZV) treated? Why should it be treated within 72 h of onset?
Acyclovir; prevent post-herpetic neuralgia
How is Ramsay Hunt syndrome treated?
PO Acyclovir plus corticosteroids
What is the MC complication of chicken pox?
Pt presents with sore throat, fever, and cervical LAD. You prescribe Ampicillin, and they return with a petechial rash. What is the dx?
Epstein-Barr Virus (EBV, infectious mononucleosis)
What is a counseling point in pts with mono?
avoid trauma/contact sports x 1 mo with splenomegaly (to prevent splenic rupture)
How is EBV (infectious mononucleosis) treated?
supportive: rest, antipyretics, analgesics (sx may last for months)
What is the MC causative organism of otitis externa?
Pt presents with 1-2 days of ear pain and itching with drainage after swimming a few days ago. Pain with traction of ear canal and tragus. What is the dx and trx?
otitis externa, ciprofloxacin/dexamethasone (ofloxacin safe with poss perforated TM)
What is a potential complication of otitis externa? How is it treated?
malignant otitis externa - osteomyelitis at skull base; IV antipseudomonal
What is a potential complication of prolonged or inadequately treated otitis media?
Pt presents with deep ear pain, fever, and mastoid tenderness. What test should be fun? What is the most likely dx and trx?
CT, mastoiditis, IV abx (same as AOM) + middle ear/mastoid drainage
What is the treatment for refractory or complicated mastoiditis?
What commonly precedes acute otitis media?
What 4 organisms MC cause acute OM?
, H influenza, Moraxella catarrhalis, Strep pyogenes
What is the treatment for choice for acute OM?
Amoxicillin (10-14 days) (Erythromycin-Sulfisoxazole if pcn allergic)
How can a Eustachian tube dysfunction be treated?
decongestants (dec ET edema), autoinsufflation, intranasal corticosteroids
What is a potential complication of Eustachian tube dysfunction?
acute otitis media
What is the MC location of a TM perforation?
What is the treatment for a TM perforation?
most heal spontaneously; avoid water, moisture, or topical aminoglycosides in ear
What is appropriate treatment for a patient who presents to the ED with an acute asthma exacerbation?
3 back to back duonebs + 2 mg/kg corticosteroid (and continue steroid at 2 mg/kg x 5 days with max of 60 mg/day)
What can be used to treat allergic rhinitis?
oral antihistamine (Cetirizine, Fexofenadine, Loratidine), intranasal steroids, decongestant (will not help rhinorrhea, sneezing, pruritus; intranasal decongestants should not be used > 3-5 days)
What is the MC cause of nasal polyps?
allergic rhinitis (trx = intranasal corticosteroids)
What is the MC site of anterior epistaxis?
What is the MC site of posterior epistaxis?
palatine artery (may cause bleeding in both nares and posterior pharynx)
What is the 1st line treatment for epistaxis? Second line?
1st: direct pressure x 10-15 min with pt seated & leaning forward (dec vessel pressure)
2nd: topical decongestants/vasoconstrictors: phenylephrine, Afrin (Oxymetazoline) (Cauterization is 3rd line if epistaxis site is visualized)
4 yom presents with unilateral mucopurulent nasal discharge with a foul odor. What is the most likely dx?
nasal foreign body
What is the MC etiology of acute pharyngotonsillitis?
viral (adenovirus, rhinovirus, enterovirus, EBV, RSV, influenza, HZV)
What is the MC bacterial cause of acute pharyngotonsillitis?
What is the trx for acute pharyngotonsillitis?
symptomatic: fluids, warm saline gargles, topical anesthetics, antipyretics
abx if S pyogenes: PCN G or VK 1st line, amoxicillin (erythromycin or clindamycin if pcn allergic)
What are the centor criteria? How many pts for abx?
1) temp > 100.4
2) tonsillar exudate
3) tender anterior cervical LAD
4) absence of cough
modified centor: add a pt if < 15; subtract a pt if > 44
4-5 pts receive abx; 2-3 receive throat culture
Name some potential complications of streptococcal pharyngitis.
rheumatic fever (preventable w/ abx) & glomerulonephritis (not preventable w/ abx)
What is the MC cause of a peritonsillar abscess? What do you do if suspected & what is the trx?
Strep pyogenes; CT first line (differentiate cellulitis vs. abscess); abx + aspiration or I&D
What is the cause of oral candidiasis? How is it diagnosed? Treated?
cause: Candida albicans
dx: white curd-like plaques (may leave behind erythema or bleed if scraped)
trx: nystatin liquid
What medication can be given in reflux to strengthen the LES?
Pt presents with sore throat, pain with swallowing, uvula deviation, and hot potato voice. What is the most likely dx and trx?
peritonsillar abscess; aspiration/I&D and/or abx (IV amoxicillin, amoxicillin-sulbactam, clindamycin; less severe cases can do PO x 7-10 d)
5 yom presents with fever, drooling, and tripod positioning. What should be ruled out? How is it dx?
epiglottitis; laryngoscopy or lateral soft tissue neck XR (thumb sign)
What is the treatment for epiglottitis?
IV Ceftizoxime or Cefuroxime & IV Dexamethasone (or other IV corticosteroid)
Why should you avoid giving Rocephin (Ceftriaxone) to neonates?
risk of kernicterus
A pediatric patient is placed on Carbamazepine for epilepsy with a dose of 5 mg/kg BID. She is continually subtherapeutic. What should be done?
divide doses into 4x daily
What is a common problem with infant dosing of Tylenol? What can you do to help?
no dosing instructions for parents; give oral syringe
A 3-year-old boy (weight, 17 kg) with a history of eczema presented to the clinic with severe pruritus. No topical remedies seemed to help.
The clinician wrote a prescription for hydralazine at 8 mg PO q6h PRN (about 2 mg/kg/d). After the prescription was picked up from the pharmacy, the patient needed to take the medication around the clock to alleviate the symptoms.
The patient was seen at the clinic again the next day because of increased lethargy and confusion. His vital signs were obtained, and he was found to be hypotensive.
What's the problem here?
Hydralazine was prescribed instead of Hydroxyzine, and it should be prescribed PRN for itching
_______________ - dilated, small, superficial blood vessel; blanches with diascopy
_______________ - thickened skin with exaggerated skin lines and distinct borders, often a result of excessive scratching or prolonged irritation
_______________ - swollen and softened by an increase in water content; the appearance skin gets when left in water too long
_______________ - irregular, rough, and convoluted surfaces; wart-like
How can irritant or allergic contact dermatitis be treated?
topical corticosteroids; Tacrolimus & Pimecrolimus (topical calcineurin inhibitor) can be used in children; systemic steroids if severe (Itching can be treated with mild soaps, oatmeal preparations, antihistamines)
What types of rashes are considered contact dermatitis?
chemical irritant, diaper rash, poison ivy or other plant exposure, dust, nickel
What is atopic dermatitis (eczema)?
chronic relapsing skin condition; IgE-mediated hypersensitivity reaction often seen with comorbid asthma or allergic rhinitis
"The itch that rashes" refers to _______________.
atopic dermatitis (eczema) (Scratching leads to lichenification, fissures, and worsening rash; secondary infections MC caused by S aureus)
What is the mainstay of treatment of atopic dermatitis?
topical corticosteroids (Tacrolimus & Pimecrolimus are topical calcineurin inhibitors that can be used for moderate to severe atopic dermatitis) (Antihistamines for itching)
When does perioral dermatitis MC occur?
young women after topical steroid use in area
Patient presents with perioral papulopustules with an erythematous base (appears acne like). She reports prior topical steroid use in area. What is the dx and trx?
perioral dermatitis; topical metronidazole or erythromycin (PO minocycline, doxycycline, or tetracycline okay too)
Patient presents with a large, isolated round/oval lesion that preceded a widespread symmetrical papular eruption. What is the most likely dx? Trx?
pityriasis rosea; supportive (lotions, antipruritics, antihistamines)
What may cause lichen planus?
graft-vs-host disease, malignant lymphoma, drug rxns (sometimes seen in Hep C)
What are the 5 Ps of lichen planus?
What is lichen planus?
an acute or chronic inflammatory dermatitis occurring in adults; involves the 5 P's: purple, polygonal, planar, pruritic, papules
What is the trx for lichen planus?
- primarily = topical corticosteroids
- severe localized lesions = intralesional steroids
- oral lesions = cyclosporine mouthwash
- severe, painful cases = systemic cyclosporine, corticosteroids, or retinoids
_______________ - an inflammatory follicular, papular, and pustular eruption involving the pilosebaceous apparatus
What may cause erythema multiforme?
- drugs (sulfonamides, phenytoin, barbiturates, pcn, allopurinol)
- infections (HSV, mycoplasma)
_______________ - lesions begin as macules and become papular, and then vesicles and bullae form in the center of the papules; target or iris lesions characteristic
erythema multiforme (EM)
How is erythema multiforme treated?
avoid precipitating factors; systemic steroids for those severely ill
What health dangers may occur with SJS or TEN?
secondary infection, fluid loss, electrolyte imbalances
Other than skin sloughing, what clinical manifestations may occur with SJS/TEN?
fever, photophobia, sore throat, mucosal inflammation, sore mouth (other: ATN, erosion in lungs and gut, bronchitis)
What lab findings may be seen in SJS/TEN? How is it dx?
anemia and lymphopenia; biopsy
What is the trx for SJS/TEN?
- remove offending agent
- burn unit for pts with extensive
- trx fluid/electrolyte imbalances
- trx any complications or infections
A finding of "spaghetti and meatballs" on KOH prep is indicative of _______________.
Pt has areas of hypopigmented macules on the trunk that do not tan. What is the likely dx?
What is the treatment for tinea versicolor?
selenium sulfide shampoo
Pt presents with a rash that is an erythematous, annular patch with distinct borders and a central clearing. What is the dx?
What is the location of tinea cruris?
What is the location of tinea barbae?
What is the location of tinea unguium?
Pt presents with pruritic burrows, vesicles, and nodules on the hands, wrists, genitalia, and axilla. What is the likely diagnosis? Trx?
scabies; topical 5% permethrin cream (antihistamines or topical steroids for itching)
What causes verrucae (warts)?
How can you distinguish 1st degree burns and 2nd degree burns?
No blisters with 1st degree burns
How can you distinguish 2nd degree burns and 3rd degree burns?
2nd degree burns are painful with application of pressure, while 3rd degree burns are a/w decreased sensation
Any burn that occurs ______________________________ should raise suspicion of upper airway involvement.
on the face, on the upper torso, or in an unconscious person
What is the mainstay treatment for burns?
What is the MC complication of burns?
secondary infection (which has potential for hematogenous spread)
What is the most effective treatment for androgenetic alopecia (male pattern baldness)?
most effect in persons with recent onset and smaller areas of hair loss
Acute urticaria is most likely caused by a(n) _______________ and lasts _______________.
allergic rxn to food or drugs; a few minutes to hours
How can acute urticaria be treated?
H1 antihistamine - Diphenhydramine (Benadryl), Hydroxyzine (Vistaril), Fexofenadine (Allegra), Cetirizine (Zyrtec)
Pt has a fever and respiratory sx x1-3 days then develops a pruritic rash that is vesicular with an erythematous base. What is the dx?
varicella (chicken pox)
Pt presents with a red face and a lacy, pink, macular rash on the torso. What is the likely dx?
erythema infectiosum (AKA Fifth Disease or Slapped Cheek - caused by
human parvovirus B19
Pt has a fever for about 4 days and then develops a pink macular rash. The fever resolves before the rash. What is the likely dx?
roseola (roseola infantum, exanthem subitum)
Pt has a fever, cough, anorexia, and coryza/rhinitis for 1-3 days and then develops a maculopapular rash from the face to extremities with Koplik spots in the mouth (white lesions on the buccal mucosa). What is the likely dx?
Pt develops a maculopapular rash from head to toe without prodromal sx. What is the most likely dx?
rubella (German measles)
Name some viral exanthems.
- erythema infectiosum
- measles (rubeola)
- rubella (German measles)
Pt has a small wound that develops thick, crusted golden "honey" yellow lesions. What is the dx?
What is the trx for impetigo?
PO: Dicloxacillin, Cefalexin, or Clindamycin (pcn allergic)
Topical: Mupirocin, Retapamulin
What is the medical term for lice?
What is the trx for lice?
topical: permethrin, pyrethrins, malathions
Pt presents with red papules/vesicles on the tongue, oral mucosa, hands, feet, and buttocks. Also c/o fever, sore throat, and malaise. What is the likely dx? Trx?
hand-foot-mouth disease (caused by Coxsackievirus); supportive
How is pertussis dx?
How is pertussis treated?
macrolide - azithromycin, clarithromycin
An unvaccinated 14 yo presents with fever, bilateral facial swelling, and inability to eat because of pain with chewing. At a FU visit 8 days later, he has a swollen and tender L testis. What is the likely dx?
mumps (vaccine typically given at 12-15 mo with booster at 4-6 yo)
3 yo presents with anal itching worse at night. She also has some wt loss, trouble sleeping, enuresis, and irritability. What is the likely dx? Trx?
pinworms (enterobiasis); all household members should be treated with Albendazole, Mebendazole, or Pyrantel (single dose given and then repeated 2-4 wks later)
What is the MC bacterial cause of PNA?
What is a good choice for outpatient trx of PNA in a patient who is otherwise healthy and without risk factors?
- macrolide: Clarithromycin or Azithromycin
What organism MC causes pneumonia in people with a h/o ETOH abuse?
What organism MC causes pneumonia in pts with a h/o COPD?
What organisms MC cause pneumonia in young people and in college settings?
What organism MC causes pneumonia in pts with a h/o cystic fibrosis?
What organism MC causes pneumonia via air conditioning or aerosolized water?
What organisms MC cause pneumonia in pts who are s/p splenectomy?
What organism MC causes pneumonia in pts with leukemia or lymphoma?
What organism MC causes pneumonia in children < 1 year?
What organism MC causes pneumonia in children < 2 years?
"Rust colored" sputum seen in a pt with pneumonia indicates the pathogen is ________________.
Bullous myringitis (infection of TM with fluid filled blisters) is a feature that may be seen with _______________ pneumonia.
What is the trx for viral PNA?
supportive measures: analgesics, fluids (Influenza: inhaled zanamivir or oral oseltamavir if indicated)
_______________ - respiratory distress in an infant caused by surfactant deficiency
hyaline membrane disease/respiratory distress syndrome (RDS)
A newborn is having respiratory difficulties. A CXR shows air bronchograms, diffuse bilateral atelectasis with a ground glass appearance, and doming of the diaphragm. What is the dx and trx?
hyaline membrane disease/respiratory distress syndrome; synchronized intermittent mandatory ventilation, exogenous surfactants as rescue
What may be affected in rheumatic fever?
heart, joints, skin, CNS
What age range is MC affected by rheumatic fever?
What heart valve is most affected by rheumatic fever?
What are the Jones criteria?
- Used to diagnose rheumatic fever
- Major criteria: carditis, erythema marginatum (pink-ringed rash), subcutaneous nodules, chorea, polyarthritis
- Minor criteria: fever, polyarthralgias, reversible prolongation of the PR interval, rapid ESR or CRP
- supportive evidence includes + throat cx or rapid strep test and elevated or rising streptococcal ab titer
What is the treatment for rheumatic fever?
- strict bed rest until stable
- IM pcn or erythromycin (pcn allergic) for documented strep infection
- salicylates for fever or joint pain, corticosteroids for joint pain
- prevention = early trx of strep pharyngitis
What changes in the heart occur with hypertrophic cardiomyopathy?
- hypertrophy (especially of the septum)
- small LV
- systolic anterior mitral motion
- diastolic dysfunction
What is done for initial treatment of hypertrophic cardiomyopathy?
BB or CCB
1 wk old infant has a crescendo-decrescendo holosystolic murmur at the LSB. Exam shows cyanosis, clubbing, and loud S2. Polycythemia present on CBC. What is the dx? Trx?
Tetralogy of Fallot; surgical repair
What is the MC congenital heart defect?
ventricular septal defect
What is heard on exam with VSD?
systolic murmur at lower LSB
How is colic defined?
rule of 3's: crying > 3 h/d, > 3d/wk for > 3 wks between the ages of 3 wks and 3 mo
This is a diagnosis of exclusion
Before diagnosing colic, what should be considered?
Dx of exclusion so consider other causes: hair in eye, corneal abrasion, strangulated hernia, OM, sepsis, etc.
How is colic treated?
- careful head to toe to r/o other causes
- improve feeding techniques (burping)
- avoid over- or underfeeding
- resolves spontaneously with time
What is the classic presentation of pyloric stenosis?
projectile, nonbilious vomiting and palpable abdominal mass in a first born male between 3 wks and 5 mo of age
How is pyloric stenosis dx? Trx?
US; pyloromyotomy (also correct dehydration and potential hypochloremic metabolic alkalosis)
A newborn in the first day of life has bilious vomiting without abdominal distention within hours of being born. H/o polyhydraminos. What is the likely dx? How is it dx and trx?
duodenal atresia; dx clinically (double bubble sign on XR 2/2 air bubbles in stomach and duodenum); trx with duodenoduodenostomy
Current jelly stools and a sausage-like mass on abdominal exam are indicative of ________________.
How is intussusception treated in children?
barium or air enema; surgery if enema fails
Parents report their 8 mo infant regurgitates several times an hour. He makes chewing movements preceding these episodes of regurgitation. What is the dx and trx?
GERD; keep upright after feeds, thicken formula with rice cereal, meds: antacids, H2 blockers, PPIs
What are the more common causes of constipation in a neonate?
Hirschsprung, intestinal pseudo-obstruction, hypothyroidism
How is constipation treated in pediatrics?
- inc oral fluid and fiber intake
- stool softeners (e.g. mineral oil)
- glycerin suppositories
- senna or docusate (cathartics)
- polyethylene glycol or milk of magnesia for short periods only if necessary (potential electrolyte imbalances)
Newborn has delayed passage of meconium with abdominal distention. What is the dx?
How does Hirschsprung disease present in older children?
chronic constipation & abdominal distention
How is Hirschsprung's Disease treated?
surgical resection of the affected bowel
_______________ - inflammation of the entire (upper and lower) GI tract, so thus involves both vomiting and diarrhea
Name the 3 MC causes of diarrhea in children.
2) Enteric adenovirus
3) Norwalk virus
What is the #1 cause of diarrhea in
enterotoxigenic E coli
What sx would indicate an inflammatory cause of diarrhea?
severe abdominal pain, tenesmus, blood/mucus in stool, fever
Tenesmus with diarrhea likely indicates _______________.
large colon involvement
What should be avoided in pts with gastroenteritis because of potential to worsen diarrhea?
soda, fruit juices, gelatin, tea
What laterality is more commonly affected by an inguinal hernia?
R (delayed descent of R testicle)
In what patient demographic are inguinal hernias MC seen?
premature male infants
The majority of inguinal hernias will resolve spontaneously within _____________.
Name some sources of vitamin A.
liver, fish oils, fortified milk, eggs
Vitamin ____ is recommended for all children with measles, regardless of country of residence.
14 mo infant presents with anorexia, pruritus, and failure to gain weight. Bulging anterior fontanel and tender swelling over both tibias. Mother buys all food at a natural foods store. What is the most likely dx?
excess vitamin A
What sx are seen with a vitamin A deficiency?
night blindness, dry skin
Name some food sources of vitamin C.
citrus fruits, strawberries, broccoli, greens
Pt presents with poor wound healing, petechiae, and bleeding gums. What is the most likely dx?
vitamin C deficiency - scurvy
Name a food source of vitamin D.
What sx is seen with excess vitamin C?
Rickets and osteomalacia are caused by _____________.
vitamin D deficiency
What clinical manifestations are seen with excess vitamin D?
hypercalcemia, kidney stones, soft tissue deposits
Name some food sources of niacin (vitamin B3).
bran, tuna, salmon, chicken, beef, liver, peanuts, grains
What sx is seen with niacin deficiency?
What groups are considered at-risk for niacin (vitamin B3) deficiency?
_____________ - repeated passes of feces into inappropriate places, whether involuntary or intentional
What are the diagnosis requirements for encopresis?
- must occur 1x a mo for 3 mo
- pt must be 4 yrs or older
What is the trx for encopresis?
- psychosocial eval
- positive reinforcement, do not punish
- older children participate in cleaning up
- set a time each day to attempt BM
- stool softeners (most encopresis cases involve constipation)
- psychotherapy, family therapy, behavioral therapy
_____________ causes most cases of hepatitis in children.
How can you test for hepatitis A?
- IgM anti-HAV at onset of illness (takes 4 mo to disappear)
- elevated ALT, AST, bilirubin, GGT
What is the most important risk factor for pediatric patients concerning hepatitis B?
perinatal exposure to hepatitis B surface antigen (HbsAg-positive mother)
Chronic _____________ & _____________ a risk factor for hepatocellular carcinoma.
hepatitis B, hepatitis C
_____________ cannot produce infection without Hepatitis B infection present also.
Name some non-viral causes of neonatal hepatitis.
congenital syphilis, toxoplasmosis
What is the trx for neonatal hepatitis?
- Abx for bacteria-associated hepatitis
- Acyclovir for HSV
- Ganciclovir and Foscarnet for CMV
What is the trx for pediatric autoimmune hepatitis?
What is Reye syndrome?
- acute encephalopathy and fatty degeneration
- hepatic dysfunction
- no other explanation for cerebral edema or hepatic abnormality
What characteristics are seen with Down syndrome (trisomy 21, 6 for dx)?
- poor Moro reflex
- hypermobility of joints
- flattened facies and occiput
- excess skin on the posterior neck
- anomalous auricles
- upward-slanting palpebral fissures
- pelvic dysplasia
- dysplasia of the middle phalanx of the 5th finger
- single transverse palmar crease
What immunization is given prior to newborn d/c?
What immunizations are given at 2 months?
- Hepatitis B
- Inactivated Polio
(2 B Dr Hip)
What immunizations are given at 4 months?
(4 Dr Hip
What immunizations are given at 6 months?
- Hepatitis B
(B Dr Hip In 6 mo)
What immunizations are given at 1-1.5 yrs?
- Hepatitis A
(1 Mad HPV)
What immunizations are given at 4-6 yrs?
(Very Dim at 4-6 pm)
What immunizations are given at 11-12 yrs?
- Human Papilloma Virus
What immunization is given at 16 years?
(Now they are Men)
_____________ or _____________ are PEx findings indicative of shaken baby syndrome.
Retinal hemorrhage, hyphema (collection of blood in anterior chamber)
How does The American College of Rheumatology define juvenile idiopathic arthritis?
- younger than 16 yrs
- duration greater than 6 weeks
- 3 subtypes: systemic, pauciarticular, polyarticular
What type of juvenile RA is characterized by spiking fevers, myalgias, polyarthralgias, and a salmon pink maculopapular rash appearing in the evening with a fever?
systemic juvenile RA
What type of juvenile RA is characterized by involvement of 4-5 medium to large joints?
pauciarticular juvenile RA
What type of juvenile RA is characterized by symmetric involvement and involves 5 or more small and large joints with possible low-grade fever, fatigue, rheumatoid nodules, and anemia?
polyarticular juvenile RA
What type of juvenile RA may have an inc ESR or CRP?
systemic juvenile RA
What type of juvenile RA may have an inc ANA?
pauciarticular juvenile RA (indicates tendency for uveitis)
What is first line treatment for juvenile RA?
- PT and OT
- 2nd line: methotrexate, lefluonomide, anakinra
What occurs anatomically with nursemaid's elbow?
slippage of radial head under the annular ligament
2 yo presents suddenly refusing to move arm. Elbow is fully pronated, and child cannot supinate. What is the dx? Trx?
- dx: nursemaid's elbow (subluxation of radial head)
- trx: elbow placed in full supination and slowly moved to full flexion
Pt presents with nursemaid's elbow, and you place the elbow in full supination and then slowly move to full flexion. How do you know when it has been reduced?
click at level of radial head + child's pain is quickly relieved
Who is at the greatest risk for idiopathic scoliosis?
girls between onset of the puberty growth spurt and cessation of spinal growth
How is scoliosis treated?
- 10-15 degrees: 6- to 12-month follow up with clinical eval and possible XRs
- 15-20 degrees: serial AP XRs q 3-4 mo for larger curves and q 6-8 mo for smaller curves or if near end of growth
- > 20 degrees: need referral to an orthopedist; possible bracing, electrical stimulation, surgery
What 5 primary carcinomas MC metastasize to bone? What is the MC site for bony metastases?
- prostate, breast, lung, kidney, thyroid
______________ - MC primary benign bone neoplasm of the hand; asymptomatic until complicated by a pathologic fracture
______________ occur 3x more often than primary bone malignancies.
Name the 3 MC types of primary sarcomas of bone.
chondrosarcoma, Ewing sarcoma, osteosarcoma
______________ is the MC primary malignant bone tumor.
______________ and ______________ are elevated with bone malignancy when the bone is broken down and remodeled.
LDH, alkaline phosphatase
______________ is necessary when working up a MSK neoplasm to determine benign vs. malignant, the cell type, and the grade of lesion.
______________ is used to MSK malignancies to determine if pulmonary metastasis is present.
______________ is used to determine the local extend of a MSK neoplasm.
Name the 2 MC types of primary intracranial tumors.
- glial cell (types include astrocytoma, ependymoma, oligodendroglioma)
______________ - primary glial cell tumor that occurs in the ependymal cells that line the ventricles and spinal canal
Name the 4 MC sources of intracranial metastasis.
lung, breast, kidney, GI tract (these are 3x more common than primary brain tumors)
______________ lesions - produce progressive intellectual decline, slowing of mental activity, personality changes, contralateral graph reflexes, expressive aphasia
______________ lesions - may cause seizures, olfactory or gustatory hallucinations, licking or smacking of the lips, depersonalization, emotional and behavioral changes, visual field defects, auditory illusions
______________ lesions - typically cause contralateral disturbances of sensation and may cause sensory sensory seizures, a cortical sensory loss or inattention
______________ lesions - characteristically produce crossed homonymous hemianopia or a partial field defect, visual agnosia for objects and colors, or unformed visual hallucinations
______________ lesions - produce cranial nerve palsies, ataxia, incoordination, nystagmus, pyramidal and sensory deficits in the limbs on one or both sides
brain stem and cerebellar
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