7 year old female
headache, sore throat, abdominal pain for two days
throat looks like this
what would you order here
Lab: RS test
7 year old female
headache, sore throat, abdominal pain for two days
what does she have
scarlet fever
what is the age group for strep
OVER 3 years old
what is always a concern with strep
rheumatic fever
glomerulonephritis
what are the symptoms like for strep around the head
sudden onset sore throat with trouble swallogin
swollen lymph nodes
fever and headache
is there nausea and vomiting in strep
yes possibly
are there URI symptoms in strep
no
what are the tonsillopharyngeal/soft palate signs of strep
tonsillopharyngeal erythema and exudate
soft palate petechiae, beefy red and swollen uvula
what types of signs are common in tonsils in strep
anterior cervical adenitis
what might you see on the belly in strep
scarlitiniform rash
why should you treat s. pharyngitis
prevents rheumatic fever and PSGN
shortens symptoms by a day
prevents transmission
what is the first line of strep treatment
penicillin or amoxicillin
why would you give amoxicillin over penicillin for s. pharyngitis
tastes better and also covers otitis media
what should you give for s. pharyngitis treatemtn if the child had penicillin allergies
azithromycin
what should you give for s. pharyngtitis treatment if the child has recently had antibiotic failure
cephalosporins or clindamycin
what if a kid shows up to your office with this after having a sore throat what is this called
scarlet fever desquamation
3 year old male with vomiting for 8 hours shows up
what should you do?
assess for unusual risk factors, intake/output, and hydration status
3 year old male with vomiting for 8 hours shows up
no unusual intake/output, been vomiting a ton and looks dehydrated, has sunken eyes, lethargic and decreased skin turgor and a sunken fontanelle
AGE
where should you check skin turgor
abdominal wall above umbilicus
what is a normal capillary refill time
less than two seconds
if a kid has AGE what is important to note
physical appearance (lethargy), dry mucus membranes, loss of tears, sunken eyes and fontennelle
do you need any diagnostics if the dehydrated kid who has been vomiting appears ill
no
what might you find in someone who is dehydrated at the labs
sodium high probably
potassium low
bicarb low
urine specific gravity high
elevated BUN
how would you treat AGE
supportive
fluids to prevent dehydration
is pedialyte necessary for AGE
no but it might be helpful
what things might the AGE kid might want to avoid in the diet for a whil
lactose and high sugar/fructose drinks
should you give AGE kids antidiarrheal agents
no
if some kid is REALLY dehydrated what should you try
Oral rehydration solution
what is in oral rehydration solution
salt and no more than 3% sugar (so no sports drinks)
should you give kids anti-emetics generally? what could you give them if you must and cost is not an object?
not phenothiazines
zofran/odansetron is ok but expensive
how does zofran/odansetron work
5-HT3 receptor antagonist
if some kid fails oral dehydration what would you order
hospitalization to IV
18 month old female with fever of 103 for 3 days
no findings on history or physical to explain fever
what is next move
check urine
if child has high fever for 4 days and then gets blanching papular rash on the trunk what is this
roseola
what age group is roseola usually in
kids under 2
is there a roseola seasonal pattern
no
will roseola go away by itself
yes
what causes roseola
HHV6
this kid is 13 months old and had a fever for two days and then this happened and they came in, what is it
roseola
24 month old male comes in with worsening abdominal distention for a month; the distention is painless but the parents are concerned
Wilm's tumor (from kidney)
what is the most common renal malignancy in children and fourth most common childhood cancer
wilm's tumor
what fraction of wilm's tumor cases are diagnosed before age 5
2/3
what % of wilm's tumor cases are diagnosed before age 10
95%
what is the tumor suppressor genes wilm's tumor is associated with errors
WT1, p53, FWT1, FWT2 and 11p15.5 locus
what cells does wilm's tumor arise from
persistent metanephric cells
what are the foci from which wilm's tumor arises referred to as
nephrogenic crests
nephroblastomatosis
what is the clinical presentation of Wilm's tumor abdominally
asymptomatic abdominal mass or swelling and/OR abdominal pain
what are some symptoms of wilm's tumor aside from the abdominal area
hematuria
fever
hypertension
upon physical examination what will wilm's tumor feel like
firm, nontender, smooth mass that is eccentrically located and rarely crosses the midline
how would the wilm's tumor be imaged best
ultrasound and CT
after imaging wilm's tumor what would the next step be
biopsy and surgical staging
what is the treatment for wilm's tumor
nephrectomy
chemo/radiation either before or after surgery
what is the wilm's tumor survival rate
90%
what are wilm's tumor patients at risk for long-term
renal insufficiency and renal failure
3 year old male with stomach flu symptoms 3 days ago, now is feeling better but he has a rash on his cheeks and lace rash on arms
what should come to mind
erythema infectiosum
what are we thinking with this rash
erythema infectiosum
what is another name for erythema infectiosum
fifth's disease
what virus causes erythema infectiosum
parvo B19
what are the general erythema symptoms for the first phase of the sickness
fever coryza (cold like), headache, nausea, diarrhea
after the nonspecific symptoms, what types of things creep into play for erythema
slapped cheek rash
what in erythema infectiosum comes after the slapped cheek rash
reticulated/lacelike rash on trunk/extremities
is erythema infectiosum self limiting
yes
what is potentially very dangerous about erythema infectiosum
fetus during 1st or 2nd trimester
9 year old girl with rash on her forearm for 3 months
although it doesnt hurt or itch, it is spreading
what is this
mulloscum
what type of virus causes molluscum
pox virus
how is mulloscum spread
direct contact and fomites, autoinoculation from scracthing, sexually transmitted
where can molluscum be present
any area of body except palms/soles
is molluscum self limiting
yes but could be montsh to years to resolve
what are some ways to treat molluscum
lesions (cryotheraphy, currette, chemical blistering agents
immune modulators
1 month old male infant, vomiting for a week
started on meds for reflux last week but didnt help
poor weight gain since first week, and projectile vomit after every feeding, non bilious, no blood, no diarrhea, no fever
what is a good next move here
check the stomach: PYLORIC STENOSIS
what is the treatment for pyloric stenosis
pylorotomy
what is pyloric stenosis from
hypertrophy of pylorus with elongation and thickeining and eventually progressing to near complete obstruction
when do sypmtoms of pyloric stenosis start to appear
between 3-5 weeks of age, rarely after 12
4 year old male complains of sore through and decreased oral intake
viral signs normal, comfortable
vesicular lesions on palms, ulcers on palate
what is this
hand, foot, and mouth disease
what if the kid with decreased oral intake and sore through with normal vital signs had just ulcers on the palate
herpangina
what causes herpangina
coxsackie viruses
how is herpangina/HFM spread
direct contact with secretions
where do ulcers appear in HFM
soft palate, hands, feet, buttocks
what are the treatment options for HFM
supportive for pain, fluid intake
who is most affected by HFM/herpangina
3-10
is herpangina/HFM self limiting
yep
2 week old 800 gm, 28 week infant in NICU with bilious residuals and temperature instability
has gotten NG feeds for 10 cc q2h for 2 days
temperature of 97.6, sluggish capillary refill
necrotizing enterocolitis
how many of NEC cases are in premature infants
90%
what is mortality of NEC
5-10%
what are a few risk factors of NEC
prematurity
microbial bowel overgrowth, impaired mucosal defense, meds that cause mucosal injury
milk feeding (not IV)
circulatory instability of intestinal tract
how does NEC present usually
apnea and lethargy (newborns)
change in feeding tolerance
abdominal distention and disocloration
do kids vomit or have diarrhea with NEC
vomit and rectal bleeding, no diarrhea
what type of draining from bilious tubes will accompany NEC
bilious
what will likely happen in untreated NEC
hypotension and septic shock
how would you diagnose NEC
heme positive stools, ab xray with dilated bowel and intraperitoneal aira nd portal venous gas
how is NEC treated
bowel rest
antibiotics
surgery
what types of antibiotics work for NEC
ampicillin, gentamicin, metronidazole
when is surgery indicated in NEC
peritonitis
pneumoperitoneum
what are the complications of NEC
stricture
short bowel syndrome
impiared neruodev and growth
2 month old female who has always had constipation and has to be stimulated rectally to have a bowel movement
did not pass meconium until day 3, mom is breast feeding and reports milk supply is good but the baby's weight gain has been marginal
no fever, no vomiting, seems fussy before having BM
what should you maybe suspect here
aganglionic megacolon
what will you need to diagnose aganglionic megacolon
rectal biopsy and air contrast enema which shows transition ponit with dilated proximal bowel in midpoint of left colon
what is the treatment for aganglionic megacolon
surgical resectino
what migration defect is aganglionic megacolon due to
defect in craniocaudal migration of neuroblasts originating from neural crest that occurs in first 12 weeks of gestation
how will aganglionic megacolon (congenital) present
failure to pass meconium in 48 hours of birth
what will a general distal intestinal obstruction show in a newborn
bilious emesis
abdominal distention
delay in passage of first meconum
what is the squirt or blast sign in aganglionic megacolon
an explosive expulsion of gas and stool after the digital rectal examinatino
what is the squirt or blast sign indicative of
congenital aganglionic megacolon
how would you diagnose aganglionic megacolon (a few ways) in a child
suction biopsy of rectal mucosa and absence of those ganglion cells
abdominal radiograph: dilated proximal loopse
contrast enema: transition zone in the rectosigmoid area and residual barium in the colon for more than 24 hours
how would you test for bowel contractility in an older child
anorectal manometry
how is anorectal manometry done
balloon to distend rectum and pressure sensor at internal anal sphincter to measure presence/absecne of rectosphincteric reflex
a 3 day old caucasian female has had no meconium since birth, and she was a full term infant with uncomplicated delivery and an unremarkable exam
abdomen is soft and anus is patent
what should you do next
contrast enema
if you image and see micro-colon and have meconium pellets, what is the diagnosis going to be AND what will you test for
meconium ileus
test for CF
when will meconium ileus present
first 3 days of life
will meconnium ileus always present with abdominal distention
yes
will meconium ileus always present with vomiting and failure to pass meconium
yes
what causes intestinal obstruction at the level of the terminal ileum
meconium pellets
what % of CF patients have meconium ileus
10%
what % of meconium ileus patients are diagnosed with CF
80-90%
what imaging would enerally be used to diagnose meconium ileus
water soluble contrast enema
what is true in meconium ileus about the ileum proximal to the obstruction
dilated
how is meconium ileus treated
enema of hyperosmolar contrast breaks up meconsium plug
8 month old male, fussy, felt warm but temperature unchecked
lots of shit like UTI, intuss, constip, herpang, meningitis, nonaccidental trauma
dont memorize this
what is a kidney infection called
pyelonephritis
what is a bladder infection called
cystitis
who has a higher risk of UTI: circumcised or uncircumcised males
uncircumcised
why do females have a higher risk of UTI
shorter urethra
what risk in particular do UTIs drive up
potential for renal damage
how does UTI present in newborns
sepsis
jaundice
diarrhea
vomiting
FTT
how does UTI present in infants
fever
abdominal pain
FTT
irritability
how does UTI present in older children
urgency, frequency, dysuria
abdominal pain
incontinence
why is UTI more difficult to diagnose in younger patients
nonspecific symptoms/unexplained fever
what MAY the physical exam show that reveals something about UTI
flank mass (hydronephrotic kidney with obstructed urine flow)
costovertebral angle tenderness (kidney pain)
what do you REALLY NEED for UTI diagnosis
urinalysis
what would indicate UTI in urinanalysis
leukocyte esterase
nitrate
would you use bag urine for culture
hell no
if you have a toilet trained infant, and you get a clean midstream catch, how many colonies/mL of a single bacterial pathogen are needed to diagnose a UTI
100,000
if you have a kid under 2 and they are not toilet trained, what are you rpboble going to do to check for UTI
bladder catheterization
how many UTIs are e. coli
80%
what usually is used for UTI treatment
2nd/3rd generation cephalosporins
if there is a young male (under 2) with recurrent UTI episodes, what should you probably check
renal ultrasound for obstruction or something underlying
what is the vesicoureteral reflux due to
incompetent or inadequate closure of the ureterovesical junction
how is reflux normally prevented during bladder contraction
fully compressing the intravesiclar ureter and sealing it off with the surrounding bladder muscles
what does VUR appear to be a risk factor for
pyelonephritis, renal scarring, and chronic damage
how many people with a UTI have VUR
30-45%
what types of people will you proble for VUR possibly in
recurrent UTI
family or personal histroy of renal anomalies
what does voiding contrast urethrogram demonstrate
reflux of urine from the bladder to the upper urinary tract
how can VUR spontaneously resolve
growth of intravesicular ureter length
when are antibiotics used in VUR
high grade reflux
what would severe VUR cases require
surgical reimplantation
what is the diseae process going on here
nothing this is a normal CXR
where should the diaphragm be in a CXR
level of 8-10 posterior rib
where should the spinous process be between in a CXR
between clavicles
which rib will the clavicle overly
3rd rib
what does this boy probably have
hyaline membrane disease
what are indistinguishable in hyaline membrane disease
heart and lung BARELY distinguishable
white male newborn at 31 weeks was born, urgent C section for placental abruption
his mother had maternal gestational diabetes, and bloody meconium stained fluid
RR 84, intermittent grunting and apnea, he was intubated and had diminished breath sounds on the left side
hyaline membrane disease
does the first or second twin classically show up with HMD
second
how co you treat HMD
surfactnt via endotracheal tube and ventilatory support
how much to antenatal steroids cut the risk for HMD
in half
when is the optimal response to antenatal steroids for a baby who is going to come out early
at least 24 hours and less than 7 days before delivery
what do you see here
bowel is actually in the chest
diaphragmatic hernia, lungs didnt develop at all
newborn in respiratory distress, 36 weeks in womb
baby grunting, tachypneic and cyanotic despite bag-mask ventilation
exam: breath sounds crackly on right, absent on left, heart sounds regular and without murmur but heart best on right
abdomen is soft and scaphoid (sucked in)
diaphragmatic hernia
where is diaphragmatic hernia usually
left side 85%
what are the results of diaphragmatic hernia medicallly
lung hypoplasia, persistent pulmonary hypertension
how is diaphragmatic hernia managed
ventilatory support or ECMO (extracorporeal membrane oxygenation)
surgical management when stable
6 month old with 3 days of runny nose, mild cough, and fever of 101
in office yesterday and diagnosed with URI but back today and rapid breathing, worsening choky cough, and difficulty eating
bronchiolitis
what is the nickname for bronchiolitis
happy wheezer
what causes most bronchiolitises
RSV
human metapneumovirus
influenza
parainfluenza
coronavirus
adenovirus
rhinovirus
when is prime season for bronchiolitis
november to april in midwest
what is the greatest risk of death for a premature infant with poor lung developemnt
RSV infection
do nearly all children have an RSV bronochiolitis by their second birthday
yes
what usually accompanies bronchiolitis
bacterial pneumonia or otitis media
how is bronciolitis treated
supportive: oxygen, IV fluids
are steroids, bronchodilatorys, or antibiotics indicated for bronchiolitis
no
what can be used to prevent bronchiolitis
palivizumab
how does RSV move in the bronchioles
syncitium (cell to cell)
what is the palivizumab antibiotic
humanized monoclonal antibody that binds to F protein (fusion protein) that allows ingress of virus into the cell)
anything odd here
steeple sign: croup
18 month old boy awakened at 2 am with barky (seal) cough, hoarse voice, and wheezing
tactile fever of at least 102
4 year old brother with cold symptoms with whom he had been eating popcornd and watching spongebob before bed
what does this guy have
croup
what is going on here
epiglottitis
what causes epiglottiis
hib
what is a tell-tale sign for epiglottitis
tripod stance
what is a more descriptive name for croup
laryngotracheitis
what type of respirations will croup give
seal bark cough, hoarseness, stridor
where is croup infecting
subglottic larynx edema/inflammation
when is the peak croup season
late fall, early winter
what causes croup
parainflu
RSV
measles
coxsackie
rhinovirus
metapneumo
influenza a and b
what is the number one pneumonia complication
influenza
what does this person have on the left but not the right
recess
14 year old with 6 days of cough, fever, headache, achiness, fatigue, red eyes
now with dry cough, temperature of 101, and right sided chest pain
pneumonia with effusion
what all viruses can cause pneumonia
RSV
influenza A or B
parainfluenza 1,2,3
adenovirus
rhinovirus
measles
what bacterial families can cause pneumos
mycoplasma
chlamydophilia
others: strep, staph, haemophilus, bordetella, myco TB
whats the first line antibiotic vs. pneumo
amoxicllin
what would be added to antibiotic regimen to include coverage for atypical pneumonias
macrolides
what is the alternate to pneumonia treatment with amoxicllin
2nd/3rd generation cephalosporin, clindamycin, levofloaxcin
how do you know that there is great inspiratory effort in a CXR
you see more ribs!
3 year old comes in with a worsening cough, runny nose, grunting noise over 36 hours
exam: distressed, RR 48, O2 sat 84%, nasal flaring, intercostal reactions, speakds two word phrases, prolonged expiratory phase, scattered wheeze
CXR: hyperexpanded, streaky hilar infiltrates
asthma
how many children have asthma
12%
what is asthma characterized by in the lungs
bronchoconstriction, inflammatio
what will FEV1 look like in asthma patient
decrased
how would you treat asthma
bronchodilator or systemic/inhaled steroid
what can too much beta2 agonist cause
tachycardia, pulmonary vascular dilation, and V/Q mismatch and hypokalemia
what's going on here
cystic fibrosis
3 month old fever, cough, respiratory distress worsening over 3 days
sats 90% on mask O2, chest crackles
labs: Na 125, Cl 77, HCO3 37
pH 7.55, pCO2 30, pO2 60
CF
what is the anion gap? what is the metabolic condition
125 Na
77 Cl
37 HCO3
11, accepbale
metabolic alkalosis due to high bicarb
what is every change of 10 in pCO2 worth
0.08 increase in pH
what can CF affect
sterility in men
lungs
pancreatits
what are the general treatments for CF
airway clearance drugs
good nutrition
preventing bacterial overgrowth
lung transplant
what types of drugs are used for CF airway clearnce
bronchodilators
inhaled sterois
DNAse
what type of nutritional change is made for CF
pancreatic enzyme replacement
what types of antibiotics help prevent bacerial overgrowth in CF
nebulized tobramycin, oral antibiotics, azithromycin