PEDS Rotation
- CVID vs THI:
- (Lack of) vs. normal response to vaccines (THI is just delayed Physiological Nadir for children to get their AB production going)
Peds Maintenance fluid requirements Calculation For body weight 0-10 kg give: For the next 10-20 kg give an additional: For each kg >20 give an additional: Formula:
- 100 mL/kg/ day - 50 mL/kg/ day - 20 mL/kg /day - Daily vol/24hr
- Pancytopenia, diffuse non-tender LAD, bone pain + petechiae, fever, fatigue, WL. - To dx?
- ALL Do BM eval
- Sudden onset of uncontrollable, continuous writhing of the arms and hands and grimacing of the face following sore throat and fever. Pericardial friction rub, ^^ ESR, P interval w/ diffuse ST elevations (pericarditis): TX:
- Acute RF d/t S. pyogenes - PCN
- R-sided weakness and aphasia (eg, single-word answers in a developmentally normal child age 4). In young children (eg, age <6), nonlocalizing symptoms e.g. headache (25%-50%), generalized or focal seizures (15%-25%), and AMS (eg, lethargy) suggest: - To Dx: - To Tx:
- Acute ischemic stroke (AIS) - Seizure tx, CT--> MRI (w/ MRA) - IV Thrombolysis/ Mechanical Thrombectomy
Empirical Tx: - Neonatal sepsis: - Lower RT infections by atypical bacteria (Mycoplasma, Chlamydia), + whooping cough: - S. aureus, MRSA, But Not H. flu: - C. diff/anaerobes: - P. aeru in CF:
- Ampi/Genta (cover GBS & E. coli. No S. aureus) - Azithromycin - Clinda - Metro - Pip/Tazo
- 3d old pt; Cessation of respiratory effort that lasts about 25 seconds. HR vv to 85/min, and Sao2 vv to 72% --> Spontaneous recovery & normalization of vitals. Physical examination after the episode is normal. Chest x-ray reveals resolving granular opacities bilaterally. Dx? - To Tx?
- Apnea of Immaturity - O2, neutral temp env't, physio necl position, Nasal CPAP, Caffeine/Theophylline
- Acute-onset fever, right lower quadrant (RLQ) pain, and leukocytosis with a neutrophilic predominance: - Acute-onset fever, right lower quadrant (RLQ) pain, and leukocytosis with a neutrophilic predominance + profuse watery and mucoid diarrhea + another sick contact with GI symptoms
- Appendicitis - Infectious ileocecitis (C. jejuni/Y. enterocolitica)
- Weakness, gait changes, urinary/fecal incontinence, and vertebrobasilar symptoms such as dizziness, vertigo, imbalance, and diplopia in pt w/ Down's Syndrome. + Upper motor neuron findings (spasticity, hyperreflexia, + Babinski sign). Cause?
- Atlantoaxial instability
- Infants: weeping, erythematous, and pruritic patches on the face, scalp, and extensor surfaces - Children: dry, scaly, and pruritic patches in the flexural regions of the body (antecubital fossa, behind the knees) and neck - Adults: dry, fissured skin with lichenification secondary to both chronic inflammation and scratching; commonly limited to the hands Dx? Tx?
- Atopic Dermatitis (Eczema) - Topical emollients (+/- low conc bleach bath to vv superinfection by bacteria, e.g S. aureus)
- Newborn w/ Central cyanosis (trunk, mucous membranes): Manage? - Newborn w/ Peripheral cyanosis (extremities): Manage?
- Attach to cardiac monitor, give O2 (pathological) - Skin to skin contact (mom's chest)
- Kid w/ preference for solitary play, lack of eye contact, and poor response-to-name when called; Restricted repetitive movements/speech; deficit in social responsiveness
- Autism Spectrum D/o (vs intellectual disability)
- Hyperkinetic movements (eg, chorea, dystonia), sensorineural hearing loss, and gaze abnormalities in a baby
- BIND (Bilirubin induced neurologic dysfunction)
- Macroglossia, Hemihypertrophy (1 side of body larger than the other); hypoglycemia: Dx? - To Dx? - Ass/w what GI Abnormality?
- Beckwith-Wiedemann Syndrome - Abdo US (+ AFP levels)--> Renal US (to check for Wilms tumor, hepatoblastoma) - Omhalocoele
- Pt w/ microcytic anemia + ^^ Hb A2 and F: Dx? - To Tx?
- Beta-thalassemia major - Chronic blood Transfusion, deferoxamine, iron chelation (SCD has Normal A2 levels)
- Initial management for precocious puberty:
- Bone age eval; hand & wrist for skeletal maturation (E.g. premature elevated estrogen in cases of precocious puberty can lead to premature epiphyseal fusion and, in turn, an advanced bone age compared to chronologic age. Conversely, if a patient's bone age correlates with chronologic age, the clinical findings are often attributed to a benign pubertal variant).
-Multiple flaccid bullae filled with thick yellow fluid; + areas of erythema and scaling around periphery of previously ruptured lesions: Dx - Tx:
- Bullous impetigo - PO Cephalexein (vs non bullous: papules and pustules w/ honey crusting; Tx w/ Top. Mupirocin)
- Week old baby, vomiting & poor feeding; sunken eyes, a depressed anterior fontanelle, and dry mucous membranes. Capillary refill is 3 seconds, and skin turgor is decreased. No abdominal masses are noted. Genital examination shows a normal uncircumcised penis with bilateral testes palpable in the scrotum; Hyponatremia, Hyperkalemia
- CAH
- A: - B: - C: - D: - E:
- Ca oxalate - Struvite - *Staghorn calculi (from struvite) - Uric Acid - Cystine
DX: - Yeast superinfection of irritant contact dermatitis Second most common diaper rash - Beefy-red confluent plaques Involves skinfolds Satellite lesions - Tx:
- Candidal Diaper dermatitis - Topical antifungal (eg, nystatin)
- Infant with seizures and hepatosplenomegaly with pic: Dx - m/c causes (2) - How to differentiate:
- Chorioretinitis (inflammation and scarring of the retina and choroid) - T. gondii/CMV - T. gondii causes Macrocephaly (head >95%ile); vs Micro/Normo in CMV
- Classic Triad for T. gondii congenital infection: - To Dx (2): - To tx (3):
- Chorioretinitis; Diffuse intracranial calcifications; Hydrocephalus - PCR/ Serology (IgA/IgM) - Pyrimethamine, sulfadiazine, folinic acid
- infant w/ Jaundice & hepatomegaly, Vomiting & poor feeding; failure to thrive; Cataracts; Increased risk for Escherichia coli sepsis: Dx? - Tx:
- Classical Galactosemia (GALT deficiency) - Galactose-free diet (soy-based formula)
- Progressive back pain when walking, bladder dysfunction and neurologic deficits (eg, weakness, hyporeflexia, abnormal gait) + Foot deformities (eg, pes cavus, hammer toe).
- Closed spinal dysraphism (Spina bifida occulta) w/ s/o tethered cord, (Can also see skin manifestations: Hair tuft, dimple, hemangioma/ lipoma)
- How to tx pts whose parents have joint custody by disagree on how to treat pt:
- Consent from only 1 parent is needed. If 1 parent agrees, proceed
- Infants age <6 months with loose stools that have mucus and blood mixed in: - Tx:
- Cow's milk-induced Allergic Proctocolitis - non-IgEp allergic rxn; Eos->RS colon - Switch to Hydrolyzed/Soy formula
- Poor linear growth, pubertal delay, and worsening headaches with papilledema (optic disc edema). Dx:
- Craniopharyngioma (suprasellar mass w/ calcifications).
- Harsh cough + inspiratory stridor-c/a: - MOA:
- Croup/parainfluenza - Infection --> edema and narrowing of prox trachea (aka laryngotracheitis)
- Meningococcal meningitis can cause this presentation. What is this? - What test should be ordered as a result?
- DIC - Serum Fibrinogen (Note that N. meningitidis will affect kids with C5-C9 deficiencies, i.e. terminal, not C3/C4)
- Child swallows coin and Xray shows pic. M/l location?
- Esophagus (Coin en face)
- Absence seizures: Tx w/? - MOA - Pic?
- Ethosuximide - Blocks T-type Ca2+ channels - 3Hz spike wave changes
Neonate w/: - Rapid Bili rise in 48-72hrs: - Total bili > 25 - Symptomatic BIND Tx w/:
- Exchange Transfusion Tx
- Child with signs of thrombocytopenia (eg, bleeding, bruising)--> leukopenia (eg, infections) and Macrocytic anemia (eg, fatigue) (d/t fetal erythropoiesis during periods of chronic hematopoietic stress) + short stature, hyper- or hypopigmentation, and absent or hypoplastic thumbs, polydactyly or a flat thenar eminence - Dx? MOA?
- Fanconi Anemia (AR) - DNA repair defect
- Infant with recent onset of infrequent, pellet-like stools after introduction of solid foods: Dx: - Anal fissure; Abdo distention/LLQ Firmness d/t: - Tx:
- Functional constipation - Stool retention - Add prune puree to diet
- Bone marrow infiltration--> thrombocytopenia and anemia; Visceral organ involvement leads to splenomegaly/ hepatomegaly. Skeletal involvement --> bony pain; Delayed puberty, poor growth Dx?
- Gaucher disease
- If mom has active Hep B infection, what to do for baby:
- Give Hep B IG and Hep B Vaccine w/in 12h of birth
- A kid who has had a splenectomy is m/l at risk of asplenia/hyposplenism. Blood smear will show these inclusions: - These inclusions are as a result of:
- H-J Bodies (Notwe: Kids w/ SCD develop Functional Asplenia by age 5) - Retained RBC nuclear remnants that are typically removed by the spleen.
- Fever, headache, seizures, and temporal lobe hyperintensity on imaging:
- HSV Encephalitis
- S3 Gallop, respiratory distress, tachycardia and murmur in kids are all signs of: - If preceded by rhinorrhea and congestion, suspect: - This presentation + hepatomegaly (>3.5cm liver palpable blw costal margin) is m/l: - Dx by:
- Heart failure - Viral prodrome (Coxsackie B/Adenovirus) - Viral myocarditis (cardiomegaly & pulm edema on CXR, vv EF on Echo) - Biopsy (Necrosis)
- The m/c complication of sickle cell trait (ASx child in family of symptomatic kids and 1 parent w/ SCD/SCT each)
- Hematuria (Hyposthenuria) (Splenic infarction is rare)
Muscle tone: - Infant botulism: - Infantile tetanus
- Hypotonia - Hypertonia
- Prophylaxis for pts w/ h/o Acute RF; to prevent RHD:
- IM PCN Benzathine G (Use B-blockers/Warfarin pt has sxs/o MS/A-Fib)
- Mgmt of pt w/ acute epiglottitis:
- Immediate eval by otolaryngologist; Endotracheal intubation if needed; Lateral radiographs if/when stable
- Factor VIII deficiency patient with bleeding refractory to replacement therapy or with increased bleeding frequency. * Joint pain in these cases=Hemarthroses; VWD will be easy bruising & mucosal bleed (also plt dysfxn)
- Inhibitor development (25% of pts) AB formed to infused FVIII
- <1y/o Blood tinged stool w/ mucus + diffuse (or intermittent) abdominal pain. FOBT +; Preceded by gastroenteritis; Intermittent episodes of inconsolable crying and flexing of hips. See pic - Dx w/: - Can also use this Meckel diverticulum is a lead point for this:
- Intussusception (Currant jelly stool) - Air enema (Target sign on Abdo US)-note: AIR (or saline), Not Barium Enema! - Nuclear Scintigraphy (w. 99-TP)
DX: - Skin breakdown from exposure to stool/urine Most common diaper rash - Erythematous papules, plaques Spares skinfolds - Tx:
- Irritant contact dermatitis - Topical barrier (eg, petrolatum, zinc oxide)
- High fever (≥39 C [102.2 F]) without a source (eg, acute otitis media, bronchiolitis); fussiness, and poor feeding +/- GI Sxs (eg, vomiting): In kids <21 d/o or unimmunized: In immunized kids >2mo/o
- Lumbar puncture (meningitis) - UTI (m/c once Pneumococcus, Hib have been covered)
Febrile seizure in < 6mo/o: Febrile seizure in 6mo-5y/o:
- Lumbar puncture/eval for meningitis - Reassurance & discharge
- Infant exposure to anesthetic, dapsone, nitrites; Cyanosis, vvSpO2; no ^^ in pulse ox after 100% O2; normal PaO2:
- Methemoglobinemia
- Rash seen in neonate/kid who is overly swaddled/bundled - To Tx?
- Milia Rubra/Heat rash - Avoid overbundling, switch to thin, cotton clothing
- Infant w/ Fever, cough, lethargy, respiratory failure, w/ numerous micronodular lesions in the liver, lungs, and spleen, a presentation highly concerning for
- Miliary tuberculosis (TB)
- Loss of motor milestones; Hypotonia; Feeding difficulties; Cherry-red macula; Hepatosplenomegaly; Areflexia: Dx? Deficiency? - Loss of motor milestones; Hypotonia; Feeding difficulties; Cherry-red macula; NO Hepatomegaly; Hyperreflexia: Dx? Deficiency?
- Neimann-Pick; Sphingomyelinase - Tay-Sachs; b-Hexoaminidase A
- Pregnant woman w/ fever --> pruritic vesicular rash. Baby is @ risk of getting: - To prevent (PEP)?
- Neonatal VZV infection - VZIG (monoclonal AB; give if mom's infection was 5 days before/2 days after delivery; Isolate from mom)
What is this rash? - To treat?
- Neonatal cephalic Pustolosis (erythematous pustules and papules on face and scalp only) - Soap and water daily (observe)
-Neonate (age ≤28 days): irritable with poor feeding and leukopenia,: Dx? - m/c c/o early-onset (age <7 days) neonatal sepsis (2): - Tx: - If pt is >1 mo/o:
- Neonatal sepsis. - GBS and Escherichia coli - Ampi/Genta - CTX/Vanc (only use Vanc in <1mo/o is MRSA is sus)
- Pt aged <15 with normal breast and pubic hair development (so Tanner Stages 3-4) but no menarche: F/u:
- No further eval; Reassurance and reevaluation
- Bedwetting at age 5+ is aka: - To Tx, use + reinforcement, bedwetting alarms, Desmopressin - For bedwetting before age 5, tx:
- Nocturnal enuresis - Reassurance (it is normal)
Neonatal Rashes Tx: - Erythema Toxicum Neonatorum (Trunk and prox. extr.; 0-3d) - Milia (Face; Birth) - Milia rubra (Any age, not at birth) - Neonatal Pustular melanosis (Birth)
- Observe and reassure (gone in 1 wk.) - Observe and reassure (gone in 1 mo.) - Avoid overheating, Topical CS if severe - Observe; Hyperpigmentation takes a while to go
- 2 bacteria involved in acute CF lung infections:
- P. aeru, S. aureus (B. cepacia is rare)
- Respiratory distress, unilaterally decreased breath sounds with increased brightness on transillumination. ^^ risk in premature infants, esp those w/ NRDS. Dx: - Tachypnea, grunting, cyanosis, and decreased breath sounds on the affected side: - Manage:
- PTX (Will see GG opacities & Air Bronchograms in NRDS) - Tension PTX - Needle thoracostomy
- Chronic enuresis, poor growth history, and report of persistent fatigue: - To Dx:
- Pediatric CKD - Measure SCr->Renal US
- Genetic condition characterized by hyperpigmented mucocutaneous macules, gastrointestinal polyps that can bleed and cause iron deficiency anemia, and an increased risk for malignancy. - To Manage?
- Peutz Yeghers - Upper and lower endoscopies, performed regularly to screen for polyps and cancer.
- Definitive Tx for SCFE:
- Physis stabilization w/ screw fixation (Closed reduction is n/r; can --> femoral head avascular necrosis d/t damaged blood suply)
- Recurrent UTIs in young BOYS: Dx? - Recurrent UTIs in young GIRLS: Dx? - Complication?
- Posterior urethral valves - Vesicoureteral reflux - Kidney failure ( Renal Interstitial Space fibrosis)
- Painful eyelid swelling and erythema - infection located in what part of eye? Here EOM are intact - Cutaneous flora infection from a break in the periorbital skin (eg, abrasion, insect bite). M/c c/a (2): - Tx? - More serious infection affecting EOM? Located where in eye? Tx?
- Preseptal cellulitis. - Anterior to the orbital septum - S. aureus/S. pyo - PO ABx - Orbital cellulitis. Posterior to orbital septum; IV ABx +/- Surgery
- Prolonged LOC, No objective findings, pt reporting Sxs occuring during the episode. EEG/ECG Normal. Occurs in front of people:
- Psychogenic Pseudosyncope (Conversion d/o) Possible psych underlying event
- Foreign body aspiration + pic. m/l location?
- R. mainstem bronchus (m/c location for aspirated foreign bodies)
- IDA vs Thal. minor:
- RDW ^ vs Normal
- Monoarticular effusion of the knee in an adolescent is most often caused by trauma, bacterial infection, or inherited blood disorder. Less common causes include late Lyme disease, juvenile arthritis, and serum sickness, all of which are typically accompanied by a preceding/ongoing:
- Rash
- Imaging of choice for peds pyelo/renal abscess: - To detect constipation: - To detect UTI w/ unusual pathogen+high fever
- Renal and Bladder US (CT has radiation; C/I in kids) - Abdo XRay - VCUG (only use AFTER abnormal US)
- Hand-wringing, seizures, ataxia, C-shaped scoliosis, and growth failure (head gowth deceleration) in 6-18mo/o Fs
- Rett Syndrome Normal development until age 6-18 months, then regression of speech, l/o purposeful hand movements (eg, twisting of fingers), stereotypical movements (eg, rocking back and forth), gait abnormalities & periodic breathing abnormalities (hyper-hypoventilation); MECP2 gene
- Several days of constitutional symptoms w/ maculopapular rash on arms and legs, thrombocytopenia, and ^^ transaminase (liver enzymes) levels: Dx? - Tx:
- Rocky Mountain spotted fever (RMSF/Rickettsia ). - Doxy
- Posterior auricular LAD, swelling in fingers and wrists bilaterally, + erythematous, Cephalocaudal, maculopapular rash, sparing palms and soles. No vaccines:
- Rubella (Measles will have the CCCK)
- Kid with vomiting, irritability, lethargy (+/- HA): - T Dx/confirm??
- S/o ^^ ICP - CT Scan (Usually in preemies w/ ventriculoperitoneal shunt)
- Watery->bloody diarrhea in kid w/in 3 days w/o fever: - Blood diarrhea w/ mucus for 3+weeks (+ travel outside US): - Watery diarrhea resolving w/in 2 days:
- STEC - E. histolytica - C. perfringens
- m/c c/o Osteomyelitis in SCD pts: - m/c c/o sepsis in SCD pts: - If unvaccinated (2):
- Salmonella enteritidis; S. aureus - S. pneumo, non-vaccine types (look for ^ fever vv BP) - H. flu, N. mening
- Neonatal Cyanosis approach:
- See pic
- Child with fever, urticarial skin rash, arthralgias, cervical lymphadenopathy, and a recent history of amoxicillin: - Key Sxs:
- Serum Sickness-Like reaction (Type III HSR with β-lactams eg, amoxicillin, cephalosporins or TMP-SMX; milder than SS - Rash, fever, and polyarthralgia w/o mucosal involvement
-Evidence of hypoxic-ischemic brain injury (eg, no response to painful stimuli in the absence of sedation) accompanied by hypertension and bradycardia. Dx:
- Severely increased intracranial pressure (ICP). (Note that Isolated pontine infarct/locked in syndrome will have eye mov't even w/o extremity mov't)
- Polyuria, nocturnal enuresis, low urine specific gravity, and normal serum sodium level.
- Sickle Cell Trait
- Asthma pt w/ cough paroxysm + crepitus (subcutaneous emphysema) + Hammn's sign (crunching sound over heart:
- Spontaneous pneumomediastinum (SPM)
- Collection of blood beneath the aponeurosis of the scalp. m/c in infants w/ vacuum assisted delivery. Firm, fluctuant mass which increases in size in a matter of hours after birth; +/- --> significant hypovolemia and anemia, ICH and skull fractures. Can cross suture lines and fontanelles. - Cannot cross suture lines & usually resolves w/in a few days: - Can cross suture lines and usually resolves w/in days-wks; d/n --> hypovolemia or other issues
- Subgaleal hemorrhage - Cephalohematoma - Caput succedaneum
- Tx for Orbital Compartment Syndrome (emergency eye swelling)
- Surgical decompression Use Dilated fundoscopy to eval AFTER decomp
- In kid: Involuntary, jerky movements (worse while awake & with action); Hypotonia; Emotional lability, obsessive-compulsive behaviors; ± Symptoms of acute rheumatic fever; Preceding GAS infection: Dx? - MOA? - GAS testing: throat culture, ASO & anti-DNAse B titers - Cardiac testing: echocardiography, ECG - Chronic antibiotics (eg, penicillin G) - Symptomatic (antidopaminergics [eg, haloperidol])
- Sydenham Chorea - Molecular mimicry between anti-GAS antibodies and neuronal Ags in basal ganglia
- Tachypnea, cyanosis, no murmur, and a single S2 w/in 24 hrs of life: - tachypnea, cyanosis, no murmur, and a single S2 w/in a few days of life:
- TGV - Hypoplastic left heart syndrome (manifests after PDA closure) (For both: Post natal O2 D/N help)
- Weakness, decreased sensation, urinary incontinence, and hyporreflexia. No UMN sxs (occurs below T12/L2). Cause? Ass. w/?
- Tethered cord syndrome - Spina bifida
- Transient hemiplegia following an episode of loss of consciousness with gradual return to baseline and normal imaging studies. Occurs in postictal period after a focal-onset seizure. Usually resolves w/in 36hrs
- Todd Paralysis
- Young kid; Constant head shrugging & hand raising; repeating what others' say; hard time making friends: - Tx Tx/Manage?
- Tourrette's (the repetitive movements are tics - Risperidone (Antipsychotic)
- Pt w/ previous fever, malaise, HA, gets OTC meds and then develops lethargy, AMS, and cerebal edema on imaging. M/l Dx:
- Toxic metabolic encephalopathy + cerebral edema d/t Hyperammonia (pos. from Salicylates/ASA used to tx earlier issue)
- Central cyanosis + peaked P waves, left axis deviation, Holosystolic murmur
- Tricuspid atresia Peaked P waves: Absent Tricuspid valve --> enlarged RA LAD: ASD d/t L-sided vol overload VSD: vv pulm markings, holosys murmur on LLSB
- Occult GI bleed: +FOBT +/- IDA - Eval w/: - If unremarkable, consider: - m/c/c: - Test w/
- U Endoscopy & Colonoscopy - SB Pathology - Meckel's diverticulum - Technetium 99 pertechnetate/Video capsule endoscopy
- Baby w/ no prenatal care & sxs/o IC hem (+ see pic):
- VKDB (Vit K deficiency bleeding)
PEP for kid exposed to VZV: - 0-1 doses of pre-vaccine: - 2 doses: Note: This vaccine can cause mild but contagious prutitic rash
- Vaccine (Not VZIG-This is for people C/I to receive vaccines, e.g. prego moms, immunocompromised) - Reassurance
- Bleeding from umbilical stump in newborn + gingival & ecchymoses: - Delayed separation of umbilical stump + recurrent infections:
- Vit K deficiency - LAD
- Kid w/ meningitis, sepsis, petechiae & purpura on skin; dies despite aggressive resuscitation efforts. Dx:
- Waterhouse-Friderichsen Syndrome (Adrenal Gland failure d/t N. Meningitidis-menigococcemia)
- Café-au-lait macules, axillary freckling, unilateral vision changes, and proptosis: Dx? - Decreased visual acuity is d/t: - Other visual issue here NOT Responsible for vv visual acuity:
- neurofibromatosis type 1 (NF1) - Large optic gliomas-->optic nerve compression - Lisch Nodules (hamartomas w/in iris
Fever ≥5 days plus ≥4 of the following: Conjunctivitis: bilateral, nonexudative Mucositis: injected/fissured lips or pharynx, strawberry tongue Cervical lymphadenopathy: ≥1 node >1.5 cm Rash: perineal erythema & desquamation; polymorphous, generalized Erythema & edema of the hands/feet, periungual desquamation
KAWASAKI DISEASE
- "Raccoon eyes" (periorbital ecchymoses) + Opsoclonus-Myoclonus
Neuroblastoma
- Test for Hereditary spherocytosis:
Osmotic fragility acidified glycerol lysis test --- abnormal eosin 5 malemide binding test
- Causes of bone & joint infections in kids
See Pic
