Medicine: Block I Cases

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NMS Medicine
Chapter 1
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7 year old female

headache, sore throat, abdominal pain for two days

throat looks like this

what would you order here

Lab: RS test

2
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7 year old female

headache, sore throat, abdominal pain for two days

what does she have

scarlet fever

3

what is the age group for strep

OVER 3 years old

4

what is always a concern with strep

rheumatic fever
glomerulonephritis

5

what are the symptoms like for strep around the head

sudden onset sore throat with trouble swallogin

swollen lymph nodes

fever and headache

6

is there nausea and vomiting in strep

yes possibly

7

are there URI symptoms in strep

no

8

what are the tonsillopharyngeal/soft palate signs of strep

tonsillopharyngeal erythema and exudate

soft palate petechiae, beefy red and swollen uvula

9

what types of signs are common in tonsils in strep

anterior cervical adenitis

10

what might you see on the belly in strep

scarlitiniform rash

11

why should you treat s. pharyngitis

prevents rheumatic fever and PSGN

shortens symptoms by a day

prevents transmission

12

what is the first line of strep treatment

penicillin or amoxicillin

13

why would you give amoxicillin over penicillin for s. pharyngitis

tastes better and also covers otitis media

14

what should you give for s. pharyngitis treatemtn if the child had penicillin allergies

azithromycin

15

what should you give for s. pharyngtitis treatment if the child has recently had antibiotic failure

cephalosporins or clindamycin

16
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what if a kid shows up to your office with this after having a sore throat what is this called

scarlet fever desquamation

17

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

18

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

19

where should you check skin turgor

abdominal wall above umbilicus

20

what is a normal capillary refill time

less than two seconds

21

if a kid has AGE what is important to note

physical appearance (lethargy), dry mucus membranes, loss of tears, sunken eyes and fontennelle

22

do you need any diagnostics if the dehydrated kid who has been vomiting appears ill

no

23

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

24

how would you treat AGE

supportive

fluids to prevent dehydration

25

is pedialyte necessary for AGE

no but it might be helpful

26

what things might the AGE kid might want to avoid in the diet for a whil

lactose and high sugar/fructose drinks

27

should you give AGE kids antidiarrheal agents

no

28

if some kid is REALLY dehydrated what should you try

Oral rehydration solution

29

what is in oral rehydration solution

salt and no more than 3% sugar (so no sports drinks)

30

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

31

how does zofran/odansetron work

5-HT3 receptor antagonist

32

if some kid fails oral dehydration what would you order

hospitalization to IV

33

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

34

if child has high fever for 4 days and then gets blanching papular rash on the trunk what is this

roseola

35

what age group is roseola usually in

kids under 2

36

is there a roseola seasonal pattern

no

37

will roseola go away by itself

yes

38

what causes roseola

HHV6

39
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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

40

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)

41

what is the most common renal malignancy in children and fourth most common childhood cancer

wilm's tumor

42

what fraction of wilm's tumor cases are diagnosed before age 5

2/3

43

what % of wilm's tumor cases are diagnosed before age 10

95%

44

what is the tumor suppressor genes wilm's tumor is associated with errors

WT1, p53, FWT1, FWT2 and 11p15.5 locus

45

what cells does wilm's tumor arise from

persistent metanephric cells

46

what are the foci from which wilm's tumor arises referred to as

nephrogenic crests
nephroblastomatosis

47

what is the clinical presentation of Wilm's tumor abdominally

asymptomatic abdominal mass or swelling and/OR abdominal pain

48

what are some symptoms of wilm's tumor aside from the abdominal area

hematuria
fever
hypertension

49

upon physical examination what will wilm's tumor feel like

firm, nontender, smooth mass that is eccentrically located and rarely crosses the midline

50

how would the wilm's tumor be imaged best

ultrasound and CT

51

after imaging wilm's tumor what would the next step be

biopsy and surgical staging

52

what is the treatment for wilm's tumor

nephrectomy

chemo/radiation either before or after surgery

53

what is the wilm's tumor survival rate

90%

54

what are wilm's tumor patients at risk for long-term

renal insufficiency and renal failure

55

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

56
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what are we thinking with this rash

erythema infectiosum

57

what is another name for erythema infectiosum

fifth's disease

58

what virus causes erythema infectiosum

parvo B19

59

what are the general erythema symptoms for the first phase of the sickness

fever coryza (cold like), headache, nausea, diarrhea

60

after the nonspecific symptoms, what types of things creep into play for erythema

slapped cheek rash

61

what in erythema infectiosum comes after the slapped cheek rash

reticulated/lacelike rash on trunk/extremities

62

is erythema infectiosum self limiting

yes

63

what is potentially very dangerous about erythema infectiosum

fetus during 1st or 2nd trimester

64
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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

65

what type of virus causes molluscum

pox virus

66

how is mulloscum spread

direct contact and fomites, autoinoculation from scracthing, sexually transmitted

67

where can molluscum be present

any area of body except palms/soles

68

is molluscum self limiting

yes but could be montsh to years to resolve

69

what are some ways to treat molluscum

lesions (cryotheraphy, currette, chemical blistering agents

immune modulators

70

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

71

what is the treatment for pyloric stenosis

pylorotomy

72

what is pyloric stenosis from

hypertrophy of pylorus with elongation and thickeining and eventually progressing to near complete obstruction

73

when do sypmtoms of pyloric stenosis start to appear

between 3-5 weeks of age, rarely after 12

74

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

75
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what if the kid with decreased oral intake and sore through with normal vital signs had just ulcers on the palate

herpangina

76

what causes herpangina

coxsackie viruses

77

how is herpangina/HFM spread

direct contact with secretions

78

where do ulcers appear in HFM

soft palate, hands, feet, buttocks

79

what are the treatment options for HFM

supportive for pain, fluid intake

80

who is most affected by HFM/herpangina

3-10

81

is herpangina/HFM self limiting

yep

82
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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

83

how many of NEC cases are in premature infants

90%

84

what is mortality of NEC

5-10%

85

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

86

how does NEC present usually

apnea and lethargy (newborns)
change in feeding tolerance
abdominal distention and disocloration

87

do kids vomit or have diarrhea with NEC

vomit and rectal bleeding, no diarrhea

88

what type of draining from bilious tubes will accompany NEC

bilious

89

what will likely happen in untreated NEC

hypotension and septic shock

90

how would you diagnose NEC

heme positive stools, ab xray with dilated bowel and intraperitoneal aira nd portal venous gas

91

how is NEC treated

bowel rest

antibiotics

surgery

92

what types of antibiotics work for NEC

ampicillin, gentamicin, metronidazole

93

when is surgery indicated in NEC

peritonitis

pneumoperitoneum

94

what are the complications of NEC

stricture
short bowel syndrome
impiared neruodev and growth

95

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

96

what will you need to diagnose aganglionic megacolon

card image

rectal biopsy and air contrast enema which shows transition ponit with dilated proximal bowel in midpoint of left colon

97

what is the treatment for aganglionic megacolon

surgical resectino

98

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

99

how will aganglionic megacolon (congenital) present

failure to pass meconium in 48 hours of birth

100

what will a general distal intestinal obstruction show in a newborn

bilious emesis
abdominal distention
delay in passage of first meconum

101

what is the squirt or blast sign in aganglionic megacolon

an explosive expulsion of gas and stool after the digital rectal examinatino

102

what is the squirt or blast sign indicative of

congenital aganglionic megacolon

103

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

104

how would you test for bowel contractility in an older child

anorectal manometry

105

how is anorectal manometry done

balloon to distend rectum and pressure sensor at internal anal sphincter to measure presence/absecne of rectosphincteric reflex

106

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

107

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

108

when will meconium ileus present

first 3 days of life

109

will meconnium ileus always present with abdominal distention

yes

110

will meconium ileus always present with vomiting and failure to pass meconium

yes

111

what causes intestinal obstruction at the level of the terminal ileum

meconium pellets

112

what % of CF patients have meconium ileus

10%

113

what % of meconium ileus patients are diagnosed with CF

80-90%

114

what imaging would enerally be used to diagnose meconium ileus

water soluble contrast enema

115

what is true in meconium ileus about the ileum proximal to the obstruction

dilated

116

how is meconium ileus treated

enema of hyperosmolar contrast breaks up meconsium plug

117

8 month old male, fussy, felt warm but temperature unchecked

lots of shit like UTI, intuss, constip, herpang, meningitis, nonaccidental trauma

dont memorize this

118

what is a kidney infection called

pyelonephritis

119

what is a bladder infection called

cystitis

120

who has a higher risk of UTI: circumcised or uncircumcised males

uncircumcised

121

why do females have a higher risk of UTI

shorter urethra

122

what risk in particular do UTIs drive up

potential for renal damage

123

how does UTI present in newborns

sepsis
jaundice
diarrhea
vomiting
FTT

124

how does UTI present in infants

fever
abdominal pain
FTT
irritability

125

how does UTI present in older children

urgency, frequency, dysuria

abdominal pain

incontinence

126

why is UTI more difficult to diagnose in younger patients

nonspecific symptoms/unexplained fever

127

what MAY the physical exam show that reveals something about UTI

flank mass (hydronephrotic kidney with obstructed urine flow)

costovertebral angle tenderness (kidney pain)

128

what do you REALLY NEED for UTI diagnosis

urinalysis

129

what would indicate UTI in urinanalysis

leukocyte esterase
nitrate

130

would you use bag urine for culture

hell no

131

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

132

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

133

how many UTIs are e. coli

80%

134

what usually is used for UTI treatment

2nd/3rd generation cephalosporins

135

if there is a young male (under 2) with recurrent UTI episodes, what should you probably check

renal ultrasound for obstruction or something underlying

136

what is the vesicoureteral reflux due to

incompetent or inadequate closure of the ureterovesical junction

137

how is reflux normally prevented during bladder contraction

fully compressing the intravesiclar ureter and sealing it off with the surrounding bladder muscles

138

what does VUR appear to be a risk factor for

pyelonephritis, renal scarring, and chronic damage

139

how many people with a UTI have VUR

30-45%

140

what types of people will you proble for VUR possibly in

recurrent UTI

family or personal histroy of renal anomalies

141

what does voiding contrast urethrogram demonstrate

reflux of urine from the bladder to the upper urinary tract

142

how can VUR spontaneously resolve

growth of intravesicular ureter length

143

when are antibiotics used in VUR

high grade reflux

144

what would severe VUR cases require

surgical reimplantation

145
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what is the diseae process going on here

nothing this is a normal CXR

146

where should the diaphragm be in a CXR

level of 8-10 posterior rib

147

where should the spinous process be between in a CXR

between clavicles

148

which rib will the clavicle overly

3rd rib

149
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what does this boy probably have

hyaline membrane disease

150

what are indistinguishable in hyaline membrane disease

heart and lung BARELY distinguishable

151

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

152

does the first or second twin classically show up with HMD

second

153

how co you treat HMD

surfactnt via endotracheal tube and ventilatory support

154

how much to antenatal steroids cut the risk for HMD

in half

155

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

156
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what do you see here

bowel is actually in the chest

diaphragmatic hernia, lungs didnt develop at all

157

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

158

where is diaphragmatic hernia usually

left side 85%

159

what are the results of diaphragmatic hernia medicallly

lung hypoplasia, persistent pulmonary hypertension

160

how is diaphragmatic hernia managed

ventilatory support or ECMO (extracorporeal membrane oxygenation)

surgical management when stable

161
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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

162

what is the nickname for bronchiolitis

happy wheezer

163

what causes most bronchiolitises

RSV
human metapneumovirus
influenza
parainfluenza
coronavirus
adenovirus
rhinovirus

164

when is prime season for bronchiolitis

november to april in midwest

165

what is the greatest risk of death for a premature infant with poor lung developemnt

RSV infection

166

do nearly all children have an RSV bronochiolitis by their second birthday

yes

167

what usually accompanies bronchiolitis

bacterial pneumonia or otitis media

168

how is bronciolitis treated

supportive: oxygen, IV fluids

169

are steroids, bronchodilatorys, or antibiotics indicated for bronchiolitis

no

170

what can be used to prevent bronchiolitis

palivizumab

171

how does RSV move in the bronchioles

syncitium (cell to cell)

172

what is the palivizumab antibiotic

humanized monoclonal antibody that binds to F protein (fusion protein) that allows ingress of virus into the cell)

173
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anything odd here

steeple sign: croup

174

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

175
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what is going on here

epiglottitis

176

what causes epiglottiis

hib

177

what is a tell-tale sign for epiglottitis

tripod stance

178

what is a more descriptive name for croup

laryngotracheitis

179

what type of respirations will croup give

seal bark cough, hoarseness, stridor

180

where is croup infecting

subglottic larynx edema/inflammation

181

when is the peak croup season

late fall, early winter

182

what causes croup

parainflu

RSV
measles
coxsackie
rhinovirus
metapneumo
influenza a and b

183

what is the number one pneumonia complication

influenza

184
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what does this person have on the left but not the right

recess

185

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

186

what all viruses can cause pneumonia

RSV
influenza A or B
parainfluenza 1,2,3
adenovirus
rhinovirus
measles

187

what bacterial families can cause pneumos

mycoplasma
chlamydophilia
others: strep, staph, haemophilus, bordetella, myco TB

188

whats the first line antibiotic vs. pneumo

amoxicllin

189

what would be added to antibiotic regimen to include coverage for atypical pneumonias

macrolides

190

what is the alternate to pneumonia treatment with amoxicllin

2nd/3rd generation cephalosporin, clindamycin, levofloaxcin

191

how do you know that there is great inspiratory effort in a CXR

you see more ribs!

192

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

193

how many children have asthma

12%

194

what is asthma characterized by in the lungs

bronchoconstriction, inflammatio

195

what will FEV1 look like in asthma patient

decrased

196

how would you treat asthma

bronchodilator or systemic/inhaled steroid

197

what can too much beta2 agonist cause

tachycardia, pulmonary vascular dilation, and V/Q mismatch and hypokalemia

198
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what's going on here

cystic fibrosis

199

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

200

what is the anion gap? what is the metabolic condition
125 Na
77 Cl
37 HCO3

11, accepbale

metabolic alkalosis due to high bicarb

201

what is every change of 10 in pCO2 worth

0.08 increase in pH

202

what can CF affect

sterility in men
lungs
pancreatits

203

what are the general treatments for CF

airway clearance drugs

good nutrition

preventing bacterial overgrowth

lung transplant

204

what types of drugs are used for CF airway clearnce

bronchodilators
inhaled sterois
DNAse

205

what type of nutritional change is made for CF

pancreatic enzyme replacement

206

what types of antibiotics help prevent bacerial overgrowth in CF

nebulized tobramycin, oral antibiotics, azithromycin