Upgrade to remove ads
Only $35.99/year

Pediatrics CLIPP Cases

Terms in this set (94)

Appropriate antibiotics started within ___ days from the start of acute sore throat and fever, with positive Group A Strep culture, will prevent acute rheumatic fever.
9
Systemic onset juvenile idiopathic arthritis (JIA)
oligoarthritis, polyarthritis, or systemic onset (Still's disease)
Typical symptoms: Prolonged fever could suggest Still's disease, rash, arthritis (although active arthritis in Still's disease often presents months to years after onset), or visceral involvement (e.g., hepatosplenomegaly, lymphadenitis, serositis)
Which diseases cause rash on the palms and soles of the feet?
Rocky mountain spotted fever, Kawasaki disease, syphilis, and enterovirus
Kawasaki disease
Vasculitis that presents with:
Fever > 5 days
Nonpurulent conjunctivitis (may have cleared prior to presentation)
Rash
Swelling and erythema of extremities
Infections that cause generalized LAD
Measles (presents with a marked generalized lymphadenopathy and splenomegaly that may last several weeks)
Infectious mononucleosis—caused by either Epstein-Barr virus or cytomegalovirus
Human immunodeficiency virus (HIV)
Histoplasmosis
Toxoplasmosis
Mycobacteria (Mycobacteria can also present as localized lymphadenopathy)
Causes of Unilateral Cervical Lymphadenopathy
Bacterial cervical adenitis
Cat scratch disease
Reactive node from an oral inflammatory or infectious process
Kawasaki disease
Mycobacterial infection (both tuberculosis and atypical mycobacteria) can present with unilateral cervical lymphadenopathy
Erythematous tongue with prominent papillae is a characteristic finding in?
streptococcal pharyngitis, Kawasaki disease, and toxic shock syndrome
Signs and symptoms of bronchiolitis
rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring
Treatment failure acute otitis media
lack of improvement in signs and symptoms within 48-72 hrs after abx therapy inititaion
Reccurent AOM
3 or > episodes of AOM in the past 6 months or 4 or > episodes in the past year
Chronic AOM: symptoms >3 months
Chronic suppurative otitis media (CSOM)
purulent otorrhea associated with chronic tympanic membrane perforation that persists for >6 weeks despite appropriate treatment.
Primarily affects people from Southeast Asia, the Western Pacific, and Africa, as well as ethnic minorities. The most common pathogens isolated from chronically draining ears of older children who have CSOM are P aeruginosa, other enteric gram-negative bacilli, and S aureus, including MRSA.
Risk factors for developing Acute or Chronic OM
Age <2 years
Atopy
Bottle propping
Chronic sinusitis
Ciliary dysfunction
Cleft palate and craniofacial anomalies
Child care attendance
Down syndrome and other genetic conditions
First episode of AOM when younger than 6 months
of age
Immunocompromising conditions
How does negative pressure in the middle ear influence AOM causality?
The accentuated negative pressure in the middle ear space may make it possible for nasopharyngeal contents to be aspirated or refluxed into the middle ear during transient opening of the eustachian tube. The accentuated negative pressure also can cause increased vascular permeability and can lead to development of an effusion. Eustachian tube dysfunction leading to negative middle ear pressure occurs in 75% of children who have viral URIs.
Most common bacterial pathogens in AOM
Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, and S pyogenes (group A Streptococcus). Staphylococcus aureus causes AOM less commonly.
Which serotype of S. pneumoniae is multidrug resistant and affects children with treatment failure and recurrent AOM the most? Also it's associated with subperiosteal abscess/mastoiditis
Serotype 19A (very similar to 19F, found in PCV7 vaccine)
S. pyogenes AOM is most commonly seen in what age group?
Children >5 years
It's a more aggressive disease with higher rates of TM perforation and mastoiditis
Bullous myringitis
blisters of TM, associated with AOM
Mild non-severe AOM is categorized by:
mild otalgia and a temperature less than 39 C in the past 24 hrs
Initial AOM therapy
amoxicillin 90 mg/kg per day bid
For patients suffering severe pain and temperature greater than 39.0°C, high-dose amoxicillin- clavulanate (90 mg/kg per day amoxicillin; 6.4 mg/kg per day clavulanate) is recommended as initial therapy.
Who benefits the most from antibiotic prophylaxis for AOM?
children younger than 2 years of age who have had multiple episodes per year benefit the most.
Most of the published studies that demonstrated benefit used either amoxicillin or sulfonamides at half the dose recommended to treat AOM given once a day. If chemoprophylaxis is attempted, usually it is provided for 6 months
Most common pathogens that cause mastoiditis
S. pneumoniae, S. pyogenes, and nontypable H. influenze
How to treat CSOM?
Topical quinalone (ciprofloxacin) (daily suctioning required for proper abx penetration)
Rotavirus vaccine schedule
RV5 is administered in three oral doses at two, four, and six months of age. RV1 is administered in two oral doses at two and four months.
Does giving aspirin to patients with Kawasaki disease reduce the instance of coronary artery aneurysms?
No, but a single dose of IVIG at a dose of 2 g/kg administered over ten to twelve hours has been shown to be more effective in reducing the risk of coronary artery aneurysms than multiple lower doses
When should patients follow up for Kawasaki disease?
1-2 weeks, for repeat echo
CAA tend to develop 4 weeks after acute illness
Monophonic vs Polyphonic wheezing
Polyphonic wheeze is characterized by multiple pitches and is typical of asthma; monophonic wheeze is characterized by only a single pitch and is typical of focal airway obstruction
How do you diagnose epilepsy?
2 or more unprovoked seizures
When would you recommend a LP for a febrile seizure kid?
If they have had incomplete immunizations (for kids 6-12 mo old)
Differences between simple and complex febrile seizures
Simple: more common, <15 min, once in 24 hrs, generalized
Complex: less common, >15 min, more than once in 24hrs, focal
Risk of recurrence of febrile seizures
If a child has his first febrile seizure before age 12 months, the recurrence risk for a second febrile seizure is about 50%.
If a child has his first febrile seizure after age 12 months, the recurrence risk is about 30%.
The risk of developing epilepsy is slightly increased above the 0.5-1% baseline population risk.
Roseola Infantum (HHV 6)
Common febrile rash illness of infants and young children under 2 years of age.
Hallmarks: high fever (38.5 to 40.5 C) for 3-5 days (sometimes with rhinorrhea), followed by abrupt resolution of fever and development of a maculopapular rash
-bulging fontanelle
-Primary HHV-6 infection is associated with approximately 20% to 30% of first febrile seizures in children.
Which enterotoxin infection of the GI tract is associated with seizures in children?
Shigella infection
Fever without source
when a complete history has been obtained and a detailed physical examination performed, and there is no identified source of the child's fever
Fever of unknown origin
defined as a temperature greater than 38.3 C (101 F) for at least two weeks' duration with failure to reach a diagnosis after one week of evaluation.
Kernig and Brudinzki's signs
Kernig's sign: Resistance to extension of the knee (from a 90 degree angle)

Brudzinski's sign: Flexion of hip and knee in response to flexion of the neck by the examiner
Opisthotonos
increased extensor tone of neck and spine leads to hyperextension of the entire spine
What cannot be given through the same IV line as ceftriaxone because they may interact and form precipitates in the lungs and kidneys?
Calcium-containing medications
Vesicoureteral reflux
Seen in 25-50% of infants after first UTI
Grades 1-2 have high rate of spontaneous resolution
Grades 3-5 should be referred to urologist. 4-5 may need surgery
Grades of vesicoureteral reflux
Grade 1: Urine refluxes part-way up the ureter.
Grade 2: Urine refluxes all the way up the ureter, but there is no dilatation of the calyces or collecting system.
Grade 3: Urine refluxes all the way up the ureter, with some dilatation of the ureter and/or blunting of the calyceal fornices
Grade 4: Urine refluxes all the way up the ureter, with marked dilatation of the ureter and blunting and dilatation of the calyces.
Grade 5: Massive reflux into a grossly dilated, tortuous ureter, with calyceal dilatation and blunting, and loss of renal cortex.
Four conditions that can lead to altered mental status that must be reversed quickly to prevent cellular damage
(1) Hypoxemia
(2) Shock (septic, hypovolemic, cardiac)
(3) Hypoglycemia
(4) Poisoning
What symptom is a late sign of shock in children?
Hypotension
Who is eligible to receive the meningococcus vaccine?
MCV4 is given to children ages 11-18.
A booster dose should be given at age 16.
College freshmen living in dorms and those in the military are considered high risk and should receive a dose of the tetravalent conjugate (MCV4) vaccine.
Complications of meningococcemia
Hearing loss
Neurologic disability
Digit or limb amputations
Skin scarring
Post-infectious cerebellitis
Post-infectious cerebellitis (otherwise known as acute cerebellar ataxia), is the most common cause of acute cerebellar ataxia in children.It is primarily a diagnosis of exclusion in children 1 to 3 years of age.Thought to be an autoimmune response leading to cerebellar demyelination.
Occurs several weeks after a viral infection (e.g., varicella or coxsackie virus).
Which drugs are typically used for migraine prophylaxis in children?
TCAs
Opsoclonus-myoclonus syndrome
a paraneoplastic syndrome that occurs most often with neuroblastoma in a young child who presents with ataxia and jerking or erratic movements as well as jerky conjugate movements of the eyes
Periventricular leukomalacia (PVL)
PVL is the result of damage to the white matter surrounding the ventricles in the brain as a result of hypoxia, ischemia, and inflammation. Correlated with intraventricular hemorrhage (bleeding from the delicate vessels of the neuronal and glial proliferation zone--germinal matrix--that surrounds the lateral ventricles in preterm infants and fetuses); it is likely that damage to the white matter is actually more widespread, but not easily visualized using current clinical imaging techniques.
PVL with cysts (cystic PVL) is highly correlated with cerebral palsy.
Dyskinetic cerebral palsy
Associated with kernicterus, due to hyperbilirubinemia, as well as findings of basal ganglia pathology on imaging. Patients typically have motor abnormalities throughout the body. Dyskinetic CP is also associated with perinatal asphyxia and can involve the thalamus and cerebellum on imaging.
Standard laboratory diagnosis for Down Syndrome
Lymphocyte karotype
Toxic ingestion
Toxic ingestion often results in vomiting, altered mental status, and obtundation. Dehydration is possible depending on the extent of vomiting and the degree to which any change in mental status impairs oral intake; the degree of dehydration in our patient seems out of proportion to the amount of vomiting. Aspirin overdose may present with tachypnea.
Abd pain is not as prevalent
4 ways to diagnose DM
1. A patient may be diagnosed with diabetes if he/she has symptoms of diabetes (polyuria, polydipsia, and unexplained weight loss) plus a random plasma glucose concentration > 200 mg/dL
2. Fasting blood glucose > 126 mg/dL
3. 2-hour postload glucose of > 200 mg/dL during an oral GTT
4. HbA1c ≥ 6.5%
Diagnosing DKA
-A random blood glucose of > 200 mg/dL
-A venous pH < 7.3 or serum bicarbonate < 15 mEq/L
-Moderate or large ketonuria or ketonemia.
At what rate do you start an insulin drip in someone with suspected DKA?
0.1 units/kg/hr, after initial volume expansion with 1 L NS bolus
Why do you NOT give bicarbonate to a patient in DKA?
Bicarbonate should not be given routinely because of the well-described paradoxical CNS acidosis and hypokalemia from rapid correction of acidosis; in addition, bicarbonate administration has been associated with an increased risk of cerebral edema-the most common cause of diabetes-associated death in children
How to calculate a corrected Na
Sodium decreases by 1.6 meq/L for each 100 mg/dL rise in glucose. Therefore, to calculate an adjusted serum sodium in the presence of hyperglycemia:

Corrected sodium = [{(measured glucose - 100) / 100} x 1.6] + measured sodium
Hypertonic/Hypernatremic (Na > 150 mEq/L) dehydration
Most severe
Possible causes of hypernatremic dehydration include breastfeeding failure, use of inappropriate rehydration solutions (boiled milk), and diabetes insipidus.
The deficit in hypernatremic dehydration is typically replaced evenly over 48 hours.Too-rapid correction of hypernatremia is associated with the development of cerebral edema.
Patients with DKA fall under this category, even if they are hyponatremic due to osmotic diuresis --> hyperosmolarity. Replace Na+ over 48 hrs
How to calculate pre-illness weight and free water deficit in a dehydrated child
If child weighs 22 kg and is 10% dehydrated, then her pre-illness weight was:
Current weight / [(100 - % dehydrated) x 0.01] = 22 / [(100-10) x 0.01] = 24.44 kg
Deficit = 24.44 kg (pre-illness weight) - 22 kg (current weight) = 2.44 kg of body weight = 2440 mL of estimated free water deficit (if 1 kg=1L)
Recommendations for screening in patients with new onset Type I DM
Anti-pancreatic Ab including insulin, GAD, and IA2
Thyroid antibodies (high incidence of autoimmune thyroid disease)
Anti-endomysial and tissue transglutaminase antibodies with a serum IgA level to rule out Celiac disease
TSH should be deferred until outpatient visit because it is likely to be abnormal due to illness
Traditional Insulin Regimen
2/3 of the total dose in the morning (1/3 rapid or short-acting, 2/3 intermediate-acting [e.g., NPH])
1/6 of the total at dinner as rapid or short-acting insulin`
1/6 of the total before bed as intermediate-acting insulin.
"Basal-bolus" Insulin Therapy
Half of the total daily dose is given in the form of an "ultra-long-acting" basal insulin given at bedtime (e.g., insulin glargine, which lasts for upwards of 24 hours), and
Half is split evenly among all 3 meals
Screening for Type II DM in children
The ADA recommends a fasting plasma glucose level, beginning at 10 years of age or at onset of puberty and then every 3 years thereafter, in children who meet the following criteria:
-Overweight (BMI >85th percentile for age and sex, weight for height > 85th percentile, or weight > 120% of ideal for height)
PLUS any two of the following risk factors:
-Maternal history of diabetes or gestational diabetes during the child's gestation.
-Family history of type 2 diabetes in a first- or second-degree relative
-Race/ethnicity (Native American, African American, Latino, or Asian American, Pacific Islander)
-Signs of insulin resistance or conditions associated with insulin resistance
Signs of cerebral edema
tachypnea, headache, vomiting, third nerve palsy, and high blood pressure
Cushing's triad
hypertension
inappropriate slowing of the heart rate
irregular respirations (Cheyne-Stokes respiration)

ICP can also present with epigastric pain, caused by vagal stimulation (increased gastric acid)
Newborn screening
All states screen for PKU and hypothyroidism.
Some states also screen for galactosemia, biotinidase deficiency, hemoglobinopathy, maple syrup urine disease (MSUD), homocystinuria, congenital adrenal hyperplasia, cystic fibrosis, G6PD deficiency, and toxoplasmosis
Many states now screen for more than 30 diseases using tandem mass spectrometry.
How do newborns handle the excretion of bile?
The newborn infant lacks the gastrointestinal flora to metabolize bile, which allows the β-glucuronidase present in the meconium to hydrolyze the conjugated bilirubin back to its unconjugated form.
The unconjugated bilirubin is then reabsorbed into the blood stream where it binds to albumin.
Newborns absorb significant quantities of bilirubin through this process, known as enterohepatic circulation
Healthy appearing newborn who develops jaundice, dark urine, and acholic stools between 3-6 weeks of age
Biliary atresia
Kasai procedure
anastomosis of the intrahepatic bile ducts to a loop of intestine to allow bile to drain directly into the intestine
How much Vitamin D should be supplemented in breastfed infants?
400 IU
Who is at higher risk for developmental dysplasia of the hip?
More commonly the left hip
-girls
-breech born
-Caucasians, Native Americans
-family hx of DDH
Which disorders tested in the newborn screen can cause newborn jaundice?
Hypothyroidism and galactosemia
Signs and symptoms of HSP
-non-thrombocytopenic purpura.
-1/3 have renal involvement, the most common manifestation of which is hematuria (renal involvement is less common in children under two years of age, occurring in about 25% in that age group)
-Arthritis, mainly of the knees and ankles, is seen in about 75%
-Colicky abdominal pain is present in 65% of patients.
-2/3 of patients report a recent upper respiratory tract infection.
How does intussusception in HSP occur?
Starts at sites of intestinal edema or submucosal hemorrhage
Toddler's fracture
fracture of the tibia is a commonly occurring fracture in young, ambulatory kids. It is not a sign of abuse. Toddler's fracture is described as a subtle, non-displaced oblique fracture of the distal tibia in kids aged 9 months to 3 years. The child will usually present with acute onset of limp and refusal to bear weight on one leg. It usually occurs when a toddler falls while twisting, or gets a foot caught and falls while trying to free the foot.
Causes of altered mental status
Alcohol, ingested toxins
Epilepsy, encephalitis, endocrine, electrolytes
Infection, insulin
Overdose, opiates, oxygen deprived
Uremia (renal failure)
Trauma, temperature
Psychosis
Stroke, shock, space occupying lesions
Mechanism of TCA Toxicity
TCAs have the following effects:
-Inhibition of synaptic reuptake of norepinephrine and serotonin
-Antagonism of muscarinic acetylcholine receptors and -peripheral alpha receptors, and
-Blockade of sodium channels and GABA receptors.

Clinically, therefore, patients present with:
-Altered mental status
-Anticholinergic signs and symptoms
-Hypotension (a hallmark of TCA toxicity)
-Dysthythmias
-Seizures
Selective serotonin reuptake inhibitor toxicity
An ingestion of an SSRI antidepressant requires a significant overdose to cause toxicity.
These overdoses cause a serotonin syndrome (profuse sweaty skin, agitation, fever, mental status changes, diarrhea, myoclonus, hyperreflexia, ataxia, and shivering)
Antidote in dextrose-refractory sulfonylurea overdose.
octreotide
Cardiac Toxicity in TCA Overdose
-Increased PR interval
-Widening of the QRS complex, and
-QT interval prolongation (which can predispose to torsades de pointes, although this is uncommon).
-Sinus tachycardia results from peripheral muscarinic antagonism and the inhibition of norepinephrine reuptake.
Treatment of TCA cardiotoxicity
Hypertonic sodium bicarbonate is given as a 1 mEq/kg bolus initially and every three to five minutes until the QRS narrows and hypotension improves. Serum alkalization is continued for 12-24 hours after the EKG normalizes because of the drug's redistribution from the tissues
Nortriptyline Overdose
Ingestion of nortriptyline 2.5 mg/kg or higher in a 2-year-old will cause significant symptoms.
Peak effect: 7-8 hours after ingestion.
Glipizide overdose
One 10 mg tablet of glipizide can cause significant hypoglycemia in a 2-year-old.

Peak effect: 2-3 hours after ingestion, but can last 24 hours.
Signs associated with anorexia
bradycardia, postural hypotension, electrolyte abnormalities, arrhythmias
Pubertal development in females
Breast buds appear (age 10-11 years), then,
Pubic hair appears (age 10-11 years) then,
Growth spurt (age 12 years) then,
Periods begin/menarche (age 12-13 years) then,
Attainment of adult height (age 15 years)
Pubertal development in males
Growth of testicles (age 12 years) then,
Pubic hair appears (age 12 years) then,
Growth of penis, scrotum (age 13-14 years) then,
First ejaculations (age 13-14 years) then,
Growth spurt (age 14 years) then,
Attainment of adult height (age 17 years)
Precordial catch syndrome
A benign condition, it occurs most commonly in adolescents and is characterized by sudden, sporadic onset of sharp pain, usually along the left sternal border, which is often exacerbated with deep inspiration. These pains are brief, lasting seconds to a few minutes, and resolve spontaneously. The pain can often be "broken" with a forced deep inspiration. Unknown etiology
-Typically sporadic, unassociated with exertion
6 month milestones-Gross motor
Rolls over
Sits unsupported
No head lag when pulled to sit from supine
6 month milestones-fine motor
Reaches for objects
Looks for dropped items
6 month milestones-language
Turns toward voice
Babbles (i.e., use of repetitive consonants: ba-ba-ba or da-da-da) (When the child says da-da-da, the family reinforces the sounds by praising the infant; then the infant makes the connection of the sound to the father.)
6 month milestones-social
Feeds self
Demonstrates stranger recognition, the prelude to stranger anxiety
12 month milestones
Gross motor: Stands alone (many can walk well).
Fine motor: Has a well developed, "neat" pincer grasp.
Language: Says "mama" and "dada" (specific) and 1 or 2 other words.
Social/adaptive: Hands parent a book to read, points when wants something, imitates activities and plays ball with examiner.
Important prognostic factors in neuroblastoma
Non-amplification of the n-myc oncogene
DNA index > 1
Favorable histology (Shimada classification)
Age < 1 year
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
When do vision and hearing screens begin?
Vision with chart at age 3
Hearing tests by age 4
Guttate psoriasis
although psoriasis can occasionally first look like eczema, it is rare in children this young. When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis is usually precipitated by a strep infection.
Sets found in the same folder