PEDIATRICS MASTER

"Common" migraine

most frequent type of migrainous headache seen in children - unilateral:frontal or temporal in location, but may involve any part of head.

12 month developmental milestone

motor (stands alone) fine (pincer grasp) lang (mama, dad, 1-2 other words) social (imitates activities and plays ball with examiner)

Two question depression screening questions

"Have you ever felt that life is not worth living?" "Have you ever felt like you wanted to kill yourself?"

Hypotonic/Hyponatremic dehydration

(Na < 130 mEq/L [< 130 mmol/L]) - occurs when sodium losses exceed those of water. - usually when patients consume diluted fluids or water in the face of dehydration. - may also be the result of adrenal insufficiency. - deficit typically replaced evenly over 24 hours.

Sedative-hypnotic drug OD symptoms

(benzodiazepines, barbiturates) - Blurred vision (miosis or mydriasis) - Hypotension - Apnea - Bradycardia - Hypothermia - Sedation, confusion, delirium, coma

Sympathomimetics OD symptoms

(cocaine, amphetamines, pseudoephedrine) Mydriasis Fever and diaphoresis Tachycardia Agitation and seizures

Tx seborrheic dermatitis

- Baby oil and a small brush to remove scales -Daily shampooing with gentle baby shampoo, or - for more persistent cases: shampoo containing ketoconazole, anti-fungal agent, or pyrithione zinc. - Care must be taken not to get the shampoo in infant's eyes. - low-potency topical steroid cream (e.g., hydrocortisone). In older children and adults, ketoconazole cream may be used.

LN of cat scratch disease

- Bartonella henselae - can be asymptomatic or symptomatic. - scratch -> subsequent infection of node or nodes draining that site. - site most commonly involved is axilla, followed by cervical, submandibular, and inguinal areas. - self-limited disease, with regression of lymph node in four to six weeks.

Screening and management of T2DM

- 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: a) Overweight - (BMI >85th percentile for age and sex, weight for height > 85th percentile, or weight > 120% of ideal for height) PLUS Any 2 of the following risk factors: - Maternal history of DM or gestational DM during child's gestation. - FMH of T2DM in first- or second-degree relative - Native American, African American, Latino, or Asian American, Pacific Islander - Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome). Management - medical therapy IN ADDITION to diet and exercise right from the time of diagnosis - Strongly suggest insulin therapy for children presenting with random blood glucose values over 250 mg/dL or HbA1c values over 9%.

UTI in infant with a fever

- Fever - Fussiness - Lack of appetite - no focus on physical examination and a relatively unremarkable review of systems.

Pulmonary TB epidemiology in children

- In the U.S., most children are infected in the home by someone close to them, but outbreaks in daycare centers and schools do occur. - case rates for all ages are highest in urban, low-income areas and in foreign-born children, among whom more than two-thirds of reported cases in the U.S. now occur.

Distributive shock

- Includes neurogenic and anaphylactic - Intravascular hypovolemia caused by: a) Vasodilation b) Increased capillary permeability c) Third-space fluid losses

CXR radiographic findings: infiltrates, volume loss, hyperinflation, mediastinal/hilar adenopathy

- Infiltrates: pneumonia, TB, cystic fibrosis or a foreign body. - Volume Loss: foreign body aspiration or significant mucus plugging. - Hyperinflation: asthma or CF - Mediastinal/Hilar Adenopathy: TB, fungal infection, or malignancy.

Mesenteric adenitis

- Inflammation of mesenteric lymph nodes. - many causes - often presents like appendicitis. - RLQ pain with fever, vomiting, DIARRHEA!!.

4 year old developmental milestones

- Knows gender and age, Friendly to other children, Plays with toys/engages in fantasy play - States first and last name, Sings a song, Most speech clearly understandable - Names colors, Aware of gender, Plays board games, Draws person with 3 parts, Copies a cross - Hops on one foot Balances for 2 seconds Pours, cuts, and mashes own food Brushes teeth

ECG findings in patient with moderate VSD

- LVH, due to LV volume overload. - Left-heart dilation by means of increased pulmonary blood flow returning to the left heart. - VSD shunt occurs in systole, when the right ventricle is also contracting, so the right ventricle ultimately does not fill with the extra volume and dilate, as the VSD flow is immediately ejected into the pulmonary arteries.

Erythema migrans

- Lesion associated with early localized Lyme disease. - Starts as a red papule at site of a tick bite. - Expands to form a large erythematous, annular patch.

Differential Dx of acute refusal to walk (9)

- Leukemia - Osteomyelitis - Reactive arthritis - Septic arthritis - Transient synovitis - Trauma - Juvenile idiopathy arthritis - Slipped capital femoral epiphysis - Legg Calve Perthes disease

5 year old developmental milestones

- Listens and attends, Can tell difference between real and make-believe, Shows sympathy/concern for others - Articulates well, Tells a simple story using full sentences, Uses appropriate tenses and pronouns, Counts to 10, Follows simple directions - Draws a person with > 6 body parts Prints some letters and numbers Copies squares and triangles - Balances on one foot, Hops and skips, Ties a knot, Has mature pencil grasp - Undresses/dresses with minimal assistance

Osteomyelitis/septic joint sxs in child

- Low-grade fever - Painful walking (if in lower extremity)

Pancreatitis PE findings

- Low-grade fevers are common. - diffuse abdominal tenderness or pain more localized to epigastric region.

Hypovolemic shock def, signs and sxs

- Most common type of shock worldwide. - From inadequate fluid intake to compensate for fluid output ( vomiting, diarrhea, hemorrhagic fluid loss). Signs and symptoms: - Mental status changes - Tachypnea - Tachycardia - Hypotension - Cool extremities - Oliguria

CXR: Diaphragmatic hernia

- Most on left side. A radiograph shows air-filled -loops of bowel in left side of chest - displacement of the heart and mediastinum to contralateral side.

Risks associated with home deliveries

- Neonatal tetanus - Omphalitis: serious infection of umbilical stump - Hemorrhagic disease of newborn (when no vitamin K is administered).

Weight after being borny

- Newborns almost always lose some weight in the first few days after birth. - Most will lose between 5 and 10% of their birth weight, and will be back to birth weight by 10-14 days of age.

Syrup of ipecac for OD

- Not first line due to potential side effects. - CI: ams (aspiration), if potential for serious cardiac side effects and seizures

Complications of sinusitis (4)

- Orbital sinusitis - Cavernous sinus thrombosis - Meningitis - Epidural abscess

All states screen for what in the newborn?

- PKU - Hypothyroidism

kernicterus

- Permanent neurologic damage due to hyperbilirubinemia - Occurs when indirect bilirubin concentration rises rapidly to high levels

Indications for a pelvic exam in a child (9)

- Persistent vaginal discharge - Dysuria or UTI symptoms in a sexually active female - Dysmenorrhea unresponsive to NSAIDs - Amenorrhea - Abnormal vaginal bleeding - Lower abdominal pain - Contraceptive counseling for IUD or diaphragm - Pap test (see note below) - Pregnancy

Erythrocytapheresis (Exchange Transfusion)

- automated method of doing exchange transfusion. - best way to rapidly lower hemoglobin S level and rapidly raise hemoglobin. - method would be used with severe respiratory distress, failing pulmonary function, or acute onset of stroke. - acute chest syndrome: increasing hemoglobin alone is usually effective to treat this life-threatening condition

Tx pertussis

- azithromycin, clarithromycin, and erythromycin. - Antibiotics given in paroxysmal phase will reduce communicability but will not alter the clinical course.

Any reagent-strip reading of whole blood glucose < 40 mg/dL must ...

- be confirmed by lab analysis of serum or plasma glucose. -Treatment should be started immediately, not delayed until laboratory results are available.

SGA

- birth weight < 3rd-10th percentile (depending on system used). - may have low birth weight due to prematurity - up to 70% of SGA infants are small simply due to constitutional factors determined by maternal ethnicity, parity, weight or height. - Consequences: hypothermia, hypoglycemia, polycythemia and hyperviscosity

LGA def, causes, sequelae

- birth weight > 90th percentile. - most important cause: maternal DM - often must be delivered by c-section, forceps, or vacuum extraction - Birth injuries more common: s fractured clavicle, brachial plexus injury, and facial nerve palsy - Hypoglycemia: especially common in LGA infants born to diabetic mothers

Strep pharyngitis

- sudden onset of fever, sore throat, headache, and abdominal pain - ABSENCE of rhinorrhea, congestion, or cough. - PE: exudative tonsillitis with palatal petechiae, strawberry tongue, tender ANTERIOR cervical LN, accentuation of skin lines in flexor surfaces (Pastia's lines) and fine papular sandpaper-like rash (scarlitiniform rash). - Treating strep throat with antibiotics will prevent the complication of acute rheumatic fever, but will NOT prevent occurrence of PSGN.

Most common cause of murmur in newborn

- occur in 70% to 80% of otherwise healthy patients at some point during their childhood, particularly between 3 and 7 years of age. - Still's murmur: musical or vibratory, and is heard best at the left lower sternal border in the supine position.

AAP rec for screening of DDH

- Serial clinical examinations of all infants' hips to age of 12 months - Hip imaging for FEMALE infants born in breech position (optional for boys) - Optional hip imaging for girls with a positive family history

Labwork for infant with hypotonia

- Serum Na, K - Serum ammonia - Glucose - TSH T4

Voiding cystourethrogram (VCUG)

- Show presence of vesicoureteral reflux - Should not be performed routinely in children after a first febrile UTI unless there are findings on renal and bladder ultrasound that suggest high-grade vesicoureteral reflux, such as hydronephrosis. - Recommended after a second febrile UTI. - VUR is seen in 25-50% of infants evaluated following their first UTI.

Intellectual disability def

- Significant degree of cognitive impairment (typically defined as performing at least 2 SD below mean on intelligence test, i.e., an intelligence quotient [IQ] < 70) - Significant degree of impaired adaptive function (ability to peform everyday tasks) Both impairments manifesting before age 18

Side effects of topical steroids

- Skin atrophy - Telangiectasias - Hypopigmentation - Suppression of HPA axis

Ectopic pregnancy sxs

- Strongly consider in any sexually active female pts with abdominal pain (EMERGENCY!) - lower abdominal pain - vaginal bleeding - abnormal menstrual history. - NOT COMMON: fever and diffuse abdominal - history of vomiting without diarrhea suggests extra-intestinal pathology.

Evaluation of Kawasaki Disease

- WBC: elevated, with neutrophlic predominance. - Hbg/Hct: normochromic, normocytic anemia - Platelets: markedly elevated platelet count but not seen until 2nd week of illness. - Liver enzymes: elevated - ESR: elevated (should not be negative) - UA: sterile pyuria

Mild dehydration sxs (3)

- Weight loss - Dry mucous membranes - Listlessness

Rate of overall IQ deficits for children with brain tumors is associated with several risk factors:

- Younger age at time of treatment - Longer time elapsed since tx - Female gender - Hydrocephalus - Use of radiation therapy, extent and dose.

B pertussis immunization

- acellular pertussis vaccine is recommended for all children. - even with full immunization, vaccine efficacy is only 70-90%. - protection from the vaccine wanes with time such that many adolescents are unprotected from pertussis unless reimmunized as is currently recommended.

Erythema multiforme

- acute hypersensitivity syndrome - symmetrical rash that starts as a dusky red macules -> esharply demarcated wheals -> target-like lesions. - stay fixed for 1-3 weeks. - Condition does not come and go. - Most commonly caused by HSV infections, but may be associated with meds.

Astrocytoma

- often have cystic component. - tx: surgical resection. - Radiation therapy reserved for patients with high-grade astrocytomas, partial resections, or pts in whom postoperative tumor progression is evident by clinical and radiologic investigation. - 5-year survival: ~90% with complete resection. - Survival rates drop to 50-70% with partial resection.

Sinusitis cough

- often preceded by URI - Nasal congestion leading to complaint of nocturnal cough due to post-nasal drip. -get headache or frequent nasal drainage.

Second line for lice

-Benzyl alcohol 5% (for children older than 6 months) or - malathion 0.5% (for children 2 years old or older) can be used in areas where resistance to permethrin or pyrethrins has been demonstrated or for a patient with a documented infestation that has failed to respond to appropriately administered therapy with permethrin or pyrethrins.

What STI do you have to report?

-Chlamydia -Gonorrhea -Syphillis -Chancroid

Predictors of septic arthritis of hip (5)

-Fever*** -Non-weight-bearing -ESR > 40 mm/hr (> 40 mm/hr) -WBC > 12.0 cells x103/μL (> 12.0 cells x109/L) - CRP >20mg/L Predicted: 0 predictors = 2% 1 predictor = 9.5% 2 predictors = 35% 3 predictors = 72.8% 4 predictors = 93%

Rocky Mountain Spotted Fever

-Fever, myalgias, headache, and petechial rash classically starting on wrists and ankles and progressing centrally. -Can get paralysis of a limb

Red flags for suspected learning disability

-History of maternal illness or substance abuse during pregnancy - Complications at the time of delivery - History of meningitis or other serious illness - History of serious head trauma - Parental history of learning disabilities or difficulty at school

increased destruction of rbcs signs

Jaundice Elevated bilirubin Dark urine Splenomegaly Schistocytes and microspherocytes on peripheral blood smear, and Low serum haptoglobin.

Causes of rash involving palms and soles

Kawasaki disease Enteroviruses Syphilis Rocky mountain spotted fever

Glipizide Toxicity in infant and peak effect

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.

Most common respiratory cause of apnea?

RSV

Common sinusitis organisms (3)

S. pneumoniae H. influenza M. catarrhalis

Complication of meningitis that involves the renal system

SIADH, but perfusing the patient is more important.

Iron ingestion OD

Severe abdominal symptoms followed by signs of shock.

ADHD prevalence

8-10%

Appropriate abx for GAS should be started within ______ days to prevent rheumatic fever.

9

Age at which neurodegenerative disease causes ataxia

<10yrs

Mottled skin

= cyanosis -signs of inadequate perfusion and oxygen delivery to the tissues.

Normal BG for infant

> 45 mg/dL (2.5 mmol/L) is normal for a newborn infant.)

HEEADSSS

H - Home E - Education and employment E - Eating disorder screening A - Activities D - Drugs S - Sexuality S - Suicide risk and depression S - Safety (fights, car, weapons)

Physiologic effects of cholinergic drug ingestion

HR decreased Diaphoretic Constricted Hyperactive abd

Physiologic effects of sedative/hypnotic drug ingestion

HR depressed BP depressed RR depressed Altered sensory exam Hypoactive abd

Microcephaly criteria

Head <10ile for gestational age

Encephalitis sxs and typical cause

Sxs: AMS and fever Cause: Usually viral

How to enhance toxin elimination:

Syrup of ipecac Activated charcoal Gastric lavage Cathartics Hemodialysis Hemoperfusion

Aortic stenosis/aortic insufficiency

Systolic ejection murmur followed by an early diastolic murmur of AI.

Patau syndrome

T13 Microphthalmia Microcephaly Severe intellectual disability Polydactyly Cleft lip and palate Cardiac and renal defects Umbilical hernias Cutis aplasia

Prophylactic medication for migraines

TCA

FS hgb

This means that both of the baby's hemoglobin genes have mutations for hemoglobin S. FS is the most common hemoglobin pattern causing sickle cell disease.

Dx of idiopathic intracranial HTN

Three dx criteria: 1. increased ICP with associated sxs 2. Normal brain anatomy 3. Normal CSF Dx test: elevated CSF opening pressure in LP.

Causes of arthritis in a child (9)

Trauma Septic arthritis Transient synovitis Reactive arthritis (e.g., post-streptococcal arthritis) Lyme disease Rheumatic fever Juvenile idiopathic arthritis Systemic lupus erythematosus Henoch-Schönlein Purpura

High rates of jaundice in what populations?

Breastfed and Mediterranean descent

Hypothyroidism in adolescent

Cold skin Slowness Fatigue Preferring hot weather to cold Doing poorly at school Coarse hair

Skeletal survey: when to do it and what you might see

Do it when: - Fractures or injuries are inconsistent with reported mechanism of injury and/or the developmental stage or abilities of the child. You might see: - Multiple fractures or injuries at different stages of healing - Fracture of femur or tibia in a non-walking child. - Posterior rib fractures,: shaken baby syndrome due to squeezing of thorax by the perpetrator's hands during shaking. - Skull fracture in an infant is also very suspicious for abuse. In these cases, it is very important to discern if mechanism of injury reported by parent or caretaker is consistent with injury seen. Involvement of a pediatric radiologist skilled in interpreting these films can be critical.

Immediate managment of someone with epiglottitis

Do not examine, wait for anesthesia/ent for acute management of airway in the OR

Most common abx to treat mod to severe acne

Doxy minocycline

GSC score

Eye out of 4 Verbal out of 5 Motor out of 6

FAC hgb

FAC means the baby is a carrier of one abnormal hemoglobin gene—for hemoglobin C. This individual has benign hemoglobin C trait—i.e., is a carrier of hemoglobin C.

FSA hgb

FSA is sickle cell beta thalassemia - one of globin genes has a mutation for S and the other has a mutation for beta thalassemia (which produces no or little normal hgb). - This pattern causes a sickling disorder, although it may behave in a milder fashion than FS (in which both genes have the sickling mutation). From a clinical management standpoint, these patients are treated in the same manner.

FSC hgb type

FSC is sickle cell hemoglobin C disease: one gene has S mutation and one gene has mutation for hemoglobin C. This pattern causes a sickling disorder, although it may behave in a milder fashion than FS (in which both genes have the sickling mutation). From a clinical management standpoint, these patients are treated in same manner.

M&M in patients with meningococcal infection

Fatality rate: - All ages: 10-15% - Adolescents: 21% Complications occur in 11% to 19% of patients and include: - Hearing loss - Neurologic disability - Digit or limb amputations - Skin scarring

Pneumonia sxs

Fever Tachypnea UNCOMMON: Altered mental status, unless the patient was severely hypoxic.

Most common indoor allergens (3)

House dust mites Animal dander Cockroaches

In a patient with dehydration and tachycardia, you resuscitate with ...

Fluid resuscitation should begin quickly with an IV fluid bolus of isotonic (0.9%, aka normal, saline) at 20 mL/kg over 60 minutes to begin to restore intravascular volume.

What tumor locations is ataxia associated with?

Frontal lobe OR cerebellum

Cough associated with gagging or choking

GERD

What do you give for patient with low fluid status, slow capillary refill?

Give a normal saline bolus, 20 mL/kg

Murmur grading

I Faint and easily missed II Obvious III Loud IV Associated with a thrill

teratoma

rare, malignant tumor can be painless or cause pressure effects (abd pain, n/v, constipation, uti)

Kernig's sign

resistance to extension of the knee

Congenital rubella

sensorineural deafness eye abnormalities (retinopathy, cataracts) patent ductus arteriosus.

HA occurring with forceful vomiting after lying down

should raise concern for increased intracranial pressure ICP

Annual influenza vaccine rec

starting at 6 months

what is guttate psoriasis precipitated by?

strep infecion

Mild intermittent asthma

symptoms fewer than two days a week or two nights a month

What disease can mimic airway obstruction?

tb

tx eczema in kids

topical steroid antihistamine. second- line: topical ant inflammatories (calcineurin inhiitors)

What should mothers with autoimmune thyroiditis expect in their newobrn

transient hypothyroidism due to transplacental passage of thyrotropin-receptor-blocking antibody

Moderate persistent asthma

when symptoms occur daily and > more than one night per week.

is not being fully toilet trained at age 3 ok?

yes.

Congenital heart defects incidence

~ 1% of newborns.

familial neuroblastoma in heritance

autosomal dominant, low penetrance

What is nephritic syndrome associated with? (4)

azotemia oliguria HTN less severe proteinuria (< 3.5 g/day).

HA that worsens with cough or valsalva

concerning for increased ICP.

Develomental screening recommended at

minimum: - 9 mos - 18 months - 24 months - 30 months.

6 month developmental milestones

motor (rolls, sits, no head lag) fine (reaches, looks for dropped items) lang (voice turn, babble) social (feeds self, stranger recognition)

A preceding history of enuresis and polydipsia is strongly suggestive of....

newly presenting diabetes

favorable prognostic factors for neuroblastoma

non ampilication of the n myc oncogene DNA index >1 favorable histology age <1yr.

do you see psoriasis in young children?

not really

RF for obesity

obese parent low SE class Genetic syndrome (ex: prader willi, bardet biedl, cohen syndrome)

Seborrheic dermatitis

- Cradle cap - erythematous plaques with fine to thick, greasy yellow scale. Typically seen on the scalp, but may spread to the ears, neck, and diaper area of infants.

Stooling Patterns in the Newborn

- Day 3: Meconium should no longer appear in stool and bowel movements should begin to appear yellow. - Day 6 or 7: Most newborns have 3-4 stools per day, although many infants pass stool with every feeding. - Stool passed by breastfed infants has little odor. You should be concerned if an infant's stool gradually loses color and becomes "acholic," as this may be a sign of biliary atresia.

Congenital adrenal hyperplasia and feeding

- Decreased feeding and activity are common in infants with CAH. - Salt-losing CAH presents with lethargy, vomiting, and dehydration that can progress to shock.

Diagnosis of Congenital Cytomegalovirus (CMV)

- Detection of CMV in urine, oral fluids, respiratory tract secretions, blood, or CSF obtained within 2 to 3 weeks of life - Polymerase chain reaction (PCR) may be used for diagnosis.

Syndromes associated with intellectual disability (3)

- Down - FAS - Fragile X

DKA labs to get

- Baseline serum osmolality prior to initiation of tx. - Baseline CBC with differential, to help identify infection as precipitating factor; interpret with caution, recognizing that the WBC count might be elevated with a left shift due to the stress of DKA alone. - Blood and/or urine cultures should be considered, especially with mental status changes, borderline hypotension, and tachycardia. - Measurement of BOHB concentrations useful to confirm ketoacidosis. Can be used to monitor response to therapy. - NOT NECESSARY: Blood lactate, pyruvate, ammonia levels -> there is explanation for AMS in a pt with DKA.

RF for Developmental Dysplasia of the Hip (DDH)

- Breech position (30-50% of DDH cases occur in infants born in breech position) - Gender (9:1 female predominance) Family history

RF for developmental dysplasia of the hip

- Breech position (30-50% of DDH cases occur in infants born in the breech position) - Gender (9:1 female predominance) - Family history

Straight vs flex bronchoscopy

- Bronchoscopy: procedure used to visualize airways. - Rigid: straight metal tube that can only be inserted through mouth. It allows one to examine upper and large airways. Because they can accommodate forceps, rigid bronchoscopes are often used for performing transbronchial biopsies and for removing foreign bodies. - Flexible bronchoscopes can be inserted through either nose or mouth, and can be used to visualize more distal airways, smaller than rigid bronchoscopes, used in young children, cannot accommodate forceps.

What exacerbates acne lesions?

- Make-up (unless noncomedogenic) - Mechanical factors such as manipulation - Occlusion, as occurs with some sports gear - Overzealous cleaning

When to send UA for culture in a pt with fever?

- Males <6 months old (< 12 months old if uncircumcised) - Females < 12 months old.

Risk Factors for Neonatal Respiratory Distress

- Maternal DM - Prematurity: lung immaturity and lack of surfactant - Maternal GBS infection: RF for neonatal sepsis (a cause of respiratory distress) -C-section delivery: predisposes to transient tachypnea of newborn (TTN) - PROM ≥ 18 hours (prolonged PROM): RF for neonatal sepsis - Meconium in amniotic fluid: risk factor for meconium aspiration syndrome

Absolute CI for breastfeeding

- Maternal HIV infection (in industrialized world) - Active herpes simplex lesions on breast - Active untreated tuberculosis - Active maternal use of some (not all) non-prescription drugs of abuse - Infants with galactosemia

Infectious cerebellitis: causes, sxs

- May be viral or bacterial - Fever is often an accompanying symptom. - Mental status changes - Viral pathogens: mumps, enteroviruses and EBV. - Bacterial pathogens: those that cause bacterial meningitis -> S. pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B.

Evaluation of suspected HSP

- Plt (normal)-to distinguish from ITP - UA- for determination of renal involvement BUN and Cr -

How to dx otitis media

- Poor mobility - at least mild bulging of the tympanic membrane - Without either of these signs, OM cannot be diagnosed. - A red tympanic membrane by itself has NO positive predictive value.

Osgood-Schlatter Disease

- condition caused by irritation of growth plate at tibial tuberosity (front of the tibia bone). It is usually a self-limited growing pain that resolves with rest and with finishing growth spurt. - Ice and NSAIDS can help with discomfort. It resolves after bones stop growing and usually causes no lasting health issues

CSF in viral meningitis

- csf glu: nl - csf glu/blood glu: nl - csf protein: nl - wbc: elevated

Pyloric stenosis sxs and signs

- escalating pattern of forceful (projectile), NON BILIOUS vomiting - obstruction is above ligament of Treitz. - Can have rapid dehydration due to inadequate fluid absorption, but typically have a vigorous appetite until late in clinical course. - often present with mild-moderate dehydration due to persistent vomiting. - hypochloremic, hypokalemic metabolic alkalosis with dehydration - Bloody emesis is sometimes seen in pyloric stenosis and other causes of forceful emesis due to the development of Mallory-Weiss tears in the esophagus. - may demonstrate a visible peristaltic wave (particularly just after eating). - palpable "olive" (hypertrophic pyloric muscle) in epigastric region.

Developmental dysplasia of the hip

- femoral head is not properly aligned with acetabulum. - spectrum includes hips that are dysplastic, dislocatable, subluxated (partially dislocated), and dislocated. - RF: female sex, breech delivery, FMH of DDH. - Screening: Ortolani maneuver, Barlow maneuver, asymmetrical gluteal folds, Imaging (female, breech) - Complications: abnormal growth of hip and permanent disability

Adverse Effects of Prenatal Substance Use:tobacco

- low birth weight in fetus.

Pseudofolliculitis

- papules, but not pustules. - often seen in the beard area. - distinguished from acne because inflammation is adjacent to hair follicles. - hair grows out of the follicle and, when shaved closely, often grows back in to the surrounding skin, causing irritation and inflammation

Opsoclonus-myoclonus syndrome

- paraneoplastic syndrome - "dancing eyes with dancing feet" - 6 months-3 years - Most often: neuroblastoma

Inhaled steroid side effects

- rare, but can occur, especially when high doses are used. -monitor for elevation in BP, serum blood sugar, growth delay, and cataract development.

Gilbert's syndrome

- reduced activity of glucuronyltransferase - relatively common cause of harmless jaundice (~5% of the population).

Decreasing the Risk of Vertical HIV Transmission

- tx of mother with combination antiretroviral therapy (if viral load > 1000 copies/mL) - C/S PRIOR to onset of labor (at 38 weeks' gestation) and rupture of membranes. - In developed nations where alternative sources of feeding are readily available, affordable, and are mixed with clean water: HIV-infected women should be counseled not to BF their infants.

Most common respiratory viruses leading to pneumonia in children

-Adenovirus -RSV -Parainfluenza -Influenza

Less common causes of wheezing in infants and toddlers (3)

-Tracheomalacia -Extrinsic compression due to vascular ring or sling, or other anatomic problem -Cystic fibrosis

Shaken baby syndrome risk factors

-Young/single parents -Significant stressors at home (finances, living situation, etc.) -Lower education level - history of seizures or irritability would increase suspicion for this diagnosis.

CXR complete obstruction in foreign body aspiration

-atelectasis (whiting out) - signs of volume loss (mediastinal shift towards affected side to compensate for loss of volume).

How often do A or B blood type children develop clinically significant jaundice from O mother?

1 in 5

Normal liver edge

1 to 2 cm below the right costal margin in a young infant.

First line tx for lice

1% permethrin lotion

Germ cell tumors produce...

1) AFP 2) HCG

Tx of primary nephrotic syndrome

1) Corticosteroids - 1-10 years w/o gross hematuria and with a normal serum complement level receive a trial of corticosteroids. 2) Sodium Restriction - During edema accumulation, pt excretes <5 mEq of Na per day. - 50 mEq/day will result in net gain of a kg of body water Q3 days. - recommend Na restriction to 1500-2000 mg daily. 3) Combination of IV Furosemide and Albumin to Treat Symptomatic Edema - Combined use of furosemide and 25% albumin recommended ONLY for children with symptomatic edema - Goal: relieve dyspnea, edema, reduce scrotal edema that compromises testicular perfusion. - - FOLLOW WITH ALBUMIN with 1 to 2 mg/kg of furosemide to promote diuresis.

Brain tumor RF

1) Exposure to ionizing radiation, and 2) Certain genetic syndromes: tuberous sclerosis, neurofibromatosis, Li-Fraumeni syndrome.

asthma exacerbation phases

1) early asthmatic rxn: - lasts for ~ 1hr. - bronchial provocation --> mast cells and eosinophils release mediators such as PGs and leukotrienes - to increased vascular permeability, mucus hypersecretion and rapid bronchoconstriction. 2), late, asthmatic reaction: - starts ~2-3 hrs after original exposure, reaches max by ~4-8 hrs and resolves in about 24 hrs. - phase is due to neutrophil, eosinophil and lymphocyte infiltration into bronchial epithelium which results in epithelial destruction, fibrotic remodeling and hyperplasia of the bronchial smooth muscle.

Differential dx of RUQ mass in 9 month old infant

1) hepatic neoplasm (sometimes no jaundice) 2) hydronephrosis 3) neuroblastoma 4) teratoma 5) wilm's tumor

When does a head injury post-traumatic seizure occur?

1-2 hours after incident

Down's syndrome referrals or evaluations in first 10 years (6)

1. Annual thyroid screening 2. Vision screening 3. Hearing screening 4. CBC in 1st month to assess for leukemoid reactions, or transient myeloproliferative disorders (TMD) 5. Referral to pediatric cardiologist (50% get structural heart disease) 6. 1 year, then annually, a hgb and hct should be obtained to screen for iron deficiency anemia Referral for evaluation by early intervention is key to a child with Down syndrome receiving any needed therapies as early as possible.

Causes of apnea in infants

1. CNS 2. Cardiac: infant with bradycardia 2ary to congenital heart block or long QT syndrome 3. Pulmonary 4. GI 5. Systemic

Hallmark chest x-ray findings of a large left-to-right shunt due to a congenital heart defect:

1. Cardiomegaly 2. Increased pulmonary vascular markings 3. Pulmonary edema

Tx guidelines for children 6 mo- 2 yrs w/ unilateral acute otitis media OR Children >2 years with unilateral or bilateral acute otitis media.

1. High dose amoxicillin 80/90mg/kg if AOM with severe sxs: - Toxic-appearing child - Persistent ear pain for 48 hours - Fever > 39 C within the past 48 hours) 2. AOM (with mild or severe symptoms) Can watch and wait if mild ear pain, temp <39 in past 48 hours.

Benefits for Child if he/she breastfeeds

1. Stimulates GI growth and motility, -> maturity of GI tract. 2. Decreases risk of acute illnesses during time that the infant is fed breast milk. 3. Lower rates of diarrhea, acute and recurrent otitis media, and UTI. 4. Reduction in incidence of obesity, cancer, adult coronary artery disease, certain allergic conditions, T1DM, and IBD. 5. Nb of studies have shown small neurodevelopmental advantages, including cognitive and motor development.

Heart defects that present with murmur and cause CHF in infancy

1. VSD 2. Severe aortic stenosis 3. Coarctation of the aorta 4. Large PDA

By what age is a newborn expected to regain birth weight?

2 weeks (6 feedings/day, 6 dirty diapers)

IV bolus

20mL/kg of NS or LR

Isabella weighs 22 kg and is approximately 10% dehydrated. She then asks you: "So how much fluid will Isabella need over the next 24-48 hours in order to replace her current fluid deficit?" You pull out your calculator and answer:

2440 mL "Think of Isabella's body as a big bag of water. Remember that: 1 gram of water = 1 mL of water; and so, 1 kg of water = 1 liter of water. Thus, for Isabella: If her currently weight is 22 kg and she is 10% dehydrated, then her pre-illness weight can be calculated with the following formula: •Pre-illness weight = 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. In most situations, the composition of the fluid and the amount of time over which it is given will depend on the serum sodium concentration and osmolarity. In DKA, however, the deficit is replaced evenly over 48 hours secondary to the hyperosmolarity.

when do you do vision screening with a chart?

3 yrs

Mild persistent asthma

3-6 days/week 3-4 nights/month.

At what ages do you typically use a booster seat?

4 to 8

Acute vs chronic cough

4 weeks split off

when do you do hearing evaluation through audiometry?

4 years

At what bili level can you see jaundice in the face?

4-5mg/dL

How much juice is recommended per day by the AAP?

4-6 ounces

GSC scale adjusted to kids <5 yrs

5 - Smiles, orientated to sounds, follows objects, interacts 4 - Cries but consolable, inappropriate interactions 3 - Inconsistently inconsolable, moaning 2 - Inconsolable, agitated 1 - No verbal response

most effective car seat restraint

5 point harness with two shoulder straps, lap belt, crotch strap

Recommended volume for mild-moderate dehydration

50-100 mL/kg.

Cyanotic heart defects

5Ts: - ToF**most common overall - Truncus arteriosus - Transposition of great arteries - Tricuspid atresia - Total anomalous pulmonary venous return: 4 veins that take blood from lungs to heart do not attach normally to left atrium. Instead, they attach to another blood vessel or the wrong part of the heart

Casey's parents just learned that Casey's screening test for CF was abnormal. What other signs and symptoms might you expect this patient to develop? A Bloody stools B Precordial thrill C Reflux D Greasy stools E Diaphoresis during feeds

A. Bloody stools would be expected in a child who had gastroenteritis or intussusception, or other intestinal anomaly. You might also expect mucus in the stool in cases of gastroenteritis or intussusception. B. A precordial thrill would be indicative of a cardiac problem, but cardiac issues are not associated with CF. C. There is no association between gastresophageal reflux disease and CF. ***D. CF causes exocrine insufficiency and ultimately results in fat malabsorption. This causes frequent foul-smelling and greasy stools. E. Diaphoresis during feeds would raise concern for congestive heart failure. The classic associated signs include tachypnea, tachycardia, and hepatomegaly.

A 4-day-old male infant was born by vaginal delivery to a 35-year-old G1P1 who declined prenatal screening. The infant has mild hypotonia, epicanthal folds, upslanting palpebral fissures and a flat face. On physical exam, he is in no acute distress, has normal oxygen saturation and has a continuous murmur. Lymphocyte karyotyping showed a particular change in chromosome number. What genetic abnormality is most likely? A Trisomy 18 B 45 X0 karyotype C Trisomy 13 D Trisomy 21 E 47 XXY karyotype

A. Edwards syndrome, caused by an extra chromosome 18. These infants present with severe mental retardation, micrognathia (small jaw), low-set ears, short neck, overlapping fingers (digits 2 and 5 overlap medially upon closure of fist), heart defects, renal malformations, limited hip abduction, and "rocker-bottom" feet (the plantar side of foot has a u-shaped curve like a rocking chair). B. Turner syndrome. Patients with Turner syndrome are female (males demise) and present with neck lymphedema (can be seen as cystic hygroma in utero), low ears, hand/foot edema, hyperconvex nails, a wide chest with valgus at the elbows. Twenty percent of patients have aorta coarctation. Many do not present classically and may be diagnosed in their early teens when stature is short and no sexual maturation ensues. Most have a normal IQ. C. Patau syndrome due to an extra chromosome 13. Presentation includes a general theme of shifting facial features toward the midline: microphthalmia (some present with a midline Cyclops eye), microcephaly with severe mental retardation, polydactyly, cleft lip and palate, cardiac and renal defects, umbilical hernias, and cutis aplasia (particularly in the midline of the scalp). ****D. Choice D is correct because an extra chromosome 21 is indicative of Down syndrome. Patients with Down syndrome will present with features described in vignette as well as small ears, redundant nuchal skin, clinodactyly (fifth digit is shorter and curved toward the radius). Additionally, cleft lip or palate, strabismus, and hypothyroidism may be seen. E. Klinefelter syndrome. These patients are males who have inherited an extra X chromosome. At birth they usually appear unremarkable without findings. Findings are variable but include testicular atrophy with resultant infertility, eunuchoid body (unusually long limbs compared to the body), and gynecomastia. IQ may be normal or in the low-normal range.

During the middle of dinner on your day off, you receive a call from one of your neighbors who remembers that you are a medical student. He is concerned about his 15-year-old daughter who had previously been in her usual state of health and has no significant past medical history. However, over the past 24 hours, his daughter suddenly spiked a fever of 103 F and has "not been herself," acting very lethargic and dazed at times. He also notes that she has been breathing heavily, not been able to eat or drink, and has not urinated over the past 12 hours. He wants your advice about whether she should be taken to the ED. Although you are fairly certain that best course of action would be to take her to the ED, you contemplate the differential diagnosis of her presentation. Given the limited history, which of the following is highest on your differential? A Acute cystitis B Diabetic ketoacidosis C CNS tumor D Meningitis E Hypoglycemia

A. Choice A is incorrect because acute cystitis is an infection that is usually limited to the lower urinary tract. While acute cystitis can present with fevers and dysuria, it would likely not present with more systemic systems, like tachypnea, altered mental status, and decreased PO intake. Such a systemic presentation would be more characteristic of bacteremia secondary to pyelonephritis. B. Choice B is incorrect because diabetic ketoacidosis is usually associated with increased (not decreased) urine output secondary to the osmotic effect of ketones and glucose in the urine. C. Choice C is incorrect because a CNS tumor would likely not result in such an acute presentation of altered mental status. ***D. meningitis is the most likely etiology in our differential given fever, altered mental status, decreased PO intake, and decreased uo. While incidence of meningitis has decreased in this patient's age range due to increased vaccinations against most common causative organisms of meningitis, it still remains high on our differential given the presentation of this patient. In the ED, we would likely need to obtain a more thorough history and physical exam as well as blood cultures and lumbar puncture to establish the diagnosis of meningitis. E. hypoglycemia is unlikely to be source of such a high-grade fever (unless patient had sepsis which resulted in high fever and hypoglycemia). Furthermore, hypoglycemia would likely not affect uo over such a significant period of time. While hypoglycemia should certainly be on differential for causes of altered mental status, presentation of fever and decreased urine output makes places it lower on our differential.

A 14-month-old female with no significant past medical history presents to clinic with fever to 39.2 C and irritability. According to mom, the patient was initially sick one week ago with a runny nose and cough, but these symptoms had resolved. She started pulling at her ear and becoming increasingly irritable last night, with her fever spiking around 2:00 a.m. this morning. Patient is up to date on immunizations, and has had several prior ear infections. She was most recently treated last month. When you examine her ears, you observe a red, bulging tympanic membrane with limited mobility in her left ear. The exam of the right ear is normal. You are confident in your diagnosis of acute otitis media. What is your treatment plan? A Observation B Anthistamines and decongestants C High-dose amoxicillin D Amoxicillin/clavulanate (with high-dose amoxicillin component) E Tympanocentesis

A. This choice is incorrect due to the patient's presentation with a high fever above 39 C. Fifty to 80% of acute otitis media cases will resolve spontaneously without antibiotics; however, the decision to defer treatment with the "observation option" is based on the child's age and illness severity. This option is limited to healthy children between the ages of 6 months to 2 years with non-severe symptoms. Our patient is presenting with severe symptoms and a high-grade fever. B. This choice is incorrect because the FDA has discouraged the use of over-the-counter cough and cold products in children younger than 2 years due to increased risk/benefit ratio. C. High-dose amoxicillin is the most common first-line treatment for acute otitis media due to its general effectiveness against susceptible and partially resistant S. pneumo, in addition to being low cost and having a high safety profile. However, this antibiotic was recently administered, raising concerns for a resistant organism. D. This choice is correct because of severe symptoms our patient is exhibiting with a high temperature greater than 39 C. Amoxicillin/clavulanate is the treatment of choice for patients with moderate to severe otalgia or high fever, and is used for additional beta-lactamase coverage for Haemophilus influenzae and Moraxella catarrhalis, and when failure with amoxicillin is suspected. E. diagnostic measure to confirm a bacterial etiology after a patient has failed repeated courses of antibiotics or if an unusually resistant organism is suspected.

An 8-year-old obese male comes to the clinic with a chief complaint of right knee pain with the right foot medially rotated. On an exam the right knee is neither swollen nor erythematous but he is noted to have a limited ROM of the right hip. In addition, when he lifts his right leg, it externally rotates. The patient did not have a URI or any trauma preceding the onset of pain. The vital signs are normal at the time of the visit and he is well appearing and afebrile. What is/are the best next step(s) in management? A AP and lateral x-ray followed by casting and crutches B Bone scan C AP and lateral x-ray followed up by internal reduction of the femoral head D Aspiration of the knee E Observation and weight reduction counseling

A. This choice would be correct if we suspected Legg-Calves-Perthes disease (avascular necrosis of capital femoral epiphysis). B. This choice is incorrect because bone scan is used to diagnose an acute hematogenous osteomyelitis. This child is not febrile and has no localized bone pain and is therefore less likely to have osteomyelitis. ***C. This choice is correct because AP and lateral x-rays are needed to diagnose a slipped capital femoral epiphysis, which is considered an emergency. This patient's age group, his obesity, and the description of the external rotation of the right leg when the hip is flexed all suggest this diagnosis. D. This choice is incorrect because the aspiration and drainage via arthroscopy is done for a septic joint. Based on physical exam and vital signs, patient is unlikely to have an infection of bone or joint.

Commonly prescribed steroids in asthma

Beclomethasone Fluticasone Budesonide Will need several weeks of daily use

Early signs of hunger in an infant

Alertness, physical activity, mouthing, rooting

Supplementation with fluoride

All should get fluoride after age of 6 months if the water supply lacks fluoride (< 0.3 ppm). Most bottled and filtered water has low fluoride levels.

Immunizations started at 12 months

MMR, Hep A, varicella

Causes of proteinuria other than nephrotic syndrome

Any disease causing inflammation of renal parenchyma (nephritis) can cause proteinuria. 1.Pyelonephritis - WBC and WBC casts would be seen with UTI, - positive leukocyte esterase test on the dipstick. 2. Acute Glomerulonephritis - varying degrees of proteinuria. - RBCs and RBC casts also present, causing positive heme test on dipstick. 3. Interstitial Nephritis - Can be associated with RBC and WBC in urine, but not a massive degree of proteinuria. - rare in children and usually caused by a med such as methicillin (no longer available in U.S.), NSAIDs, penicillins, cephalosporins, rifampin, sulfonamides, or infection.

At a routine well-child visit, the frantic mother of your 4-year-old male patient states that she thinks her son has some developmental delays based on what she hears from other parents. Although he knows how to do such things as throw a ball and copy a circle, he cannot brush his teeth on his own, tie his shoes, or hop on one foot. According to the AAP's Bright Futures, which of the following are development milestones for typical 4-year-olds? Please select one answer. A Throw a ball overhand, ride tricycle, build tower of 6-8 cubes B Hop on 1 foot, copy a cross, brush teeth C Tie a knot, copy squares D Mature pencil grasp, print some letters and numbers E Skip, draw a person with 6 or more body parts

B has been selected by the expert. A. This choice is incorrect. Throwing a ball overhand, riding a tricycle, building a tower of 6-8 cubes, and copying a circle are developmental milestones for 3-year-olds. B. This choice is correct. A a normally developing 4-year-old should be able to hop on 1 foot, copy a cross, pour/cut/mash their own food, and brush teeth. C, D, E. This choice is incorrect. These are milestones for 5-year-olds.

A 9-year-old female is brought to clinic by her mother because of two days of abdominal pain and vomiting. She has vomited six times today and has had decreased appetite, but no diarrhea, fevers, sick contacts, or changes in diet. Her mom states that she has been otherwise healthy apart from increased thirst and occasional bedwetting over the last few weeks. Of note, patient's maternal grandmother suffers from celiac disease. On exam, patient is afebrile and has a HR of 180 bpm, BP 90/60 mmHg, RR 50 bpm, and O2 saturation of 98%. She is lying in bed appearing slightly drowsy, taking rapid, deep breaths and is slow to respond to questions. Her heart and lung exams are normal apart from being tachycardic, and abdominal exam reveals mild diffuse tenderness to palpation with no rebound or guarding. Which of the following would be the most appropriate next step in management? Please select one answer. A Chest x-ray B Urine culture C Fingerstick glucose D Abdominal ultrasound E Gastric lavage

C has been selected by the expert. A. A chest x-ray would be appropriate if bacterial pneumonia were high on your differential. A patient with pneumonia generally presents with fever, cough, tachypnea, and will likely have characteristic lung findings such as crackles on exam. The patient may experience abdominal pain secondary to pleural inflammation; however, vomiting is not a common presentation. The absence of fever, cough, sick contacts, and lung findings on exam make pneumonia a less likely diagnosis. B. Urine culture would be appropriate if pyelonephritis were high on your differential. A patient with pyelonephritis may present with history of fever, dysuria, urinary frequency, CVA tenderness, and vomiting. However, this patient's overall clinical picture does not support the diagnosis, since the patient is afebrile without a history of dysuria or classic CVA tenderness. C. Obtaining a fingerstick glucose is the diagnostic step with the highest yield since the patient's clinical picture is strongly indicative of diabetic ketoacidosis (DKA). DKA is a condition more closely associated with type 1 (rather than type 2) diabetes, and is formally diagnosed if a random glucose is > 200 mg/dL, venous pH is < 7.3 and/or bicarbonate < 15 mEq/L and there is ketonemia or ketonuria. Patients in DKA can present with abdominal pain and vomiting secondary to metabolic acidosis that stems from ketonemia and lactic acidosis. Furthermore, osmotic diuresis from hyperglycemia may contribute to dehydration, which can manifest as tachycardia, hypotension, and altered mental status. In an attempt to compensate for the metabolic acidosis, the patient may also present as tachypneic with characteristic Kussmaul respirations (rapid, deep breaths). This patient's history of polydipsia, enuresis, and family history of autoimmune disease (including celiac disease and Hashimoto's thyroiditis) suggest that the patient has type 1 diabetes. Her current vital signs and general state of lethargy also point towards DKA and should be confirmed with a fingerstick glucose (in addition to other tests). D. Abdominal ultrasound would be indicated if appendicitis were high on your differential. Appendicitis may present with fever, nausea, vomiting, diarrhea, decreased appetite, and abdominal pain that localizes to the RLQ. Physical exam findings may include a positive Rovsing's sign or a positive psoas or obturator sign. Ultrasound may be a useful tool in detecting appendicitis in children. Appendicitis is less likely in this patient since she is afebrile and does not have the classic localizing pain characteristic of this condition. E. Gastric lavage may be the indicated next step of management if toxic ingestion is the confirmed diagnosis. A patient who has ingested toxic substance is usually afebrile and obtunded and may present with vomiting and manifestations of dehydration (secondary to vomiting). In a patient with salicylate toxicity, tachypnea is a common presentation. A thorough history to assess exposure to toxins and sending urine for evaluation of toxins may be appropriate to make this diagnosis. Given this patient's overall picture, DKA is a more likely diagnosis.

All children with cough >3weeks get a ...

CXR

Important step when suspecting an ingestion by child

Call poison control center

Are febrile seizures hereditary?

Can be!

MCV4 and MenB

Complete meningococcal immunization consists of 2 separate vaccines: - MCV4 includes serotypes A,C,W and Y - MenB includes serotype B 1) MCV4: First dose routinely given at age 11 years, with a booster dose at age 16 years 2) MenB: One dose given at 16 years *For high risk populations, MCV4 is indicated as early as 2 months

A 6-week-old infant girl whose family recently immigrated from Mexico is brought to clinic for "excessive sleepiness." The mother states the infant is not easily aroused for feedings and is not as active as she was previously. She is also concerned about her daughter's large "outtie" belly button. On exam, the patient is afebrile and jaundiced, with a puffy myxedematous face. The fontanels are large but flat. There is a large umbilical hernia. When asked about the results of a newborn screening exam, mom states that the screening was never performed. What would be an expected abnormal lab value(s) associated with her condition? A Low sodium, high potassium B Glucose < 40 mg/dL C High WBC with bandemia D High TSH, low T4

Correct is d A. A low sodium and high potassium in a lethargic infant would suggest the diagnosis of congenital adrenal hyperplasia (CAH), characterized by a decreased production of cortisol and aldosterone. Low aldosterone results in decreased stimulation of the H/K exchange in the collecting duct, hence loss of sodium, retention of potassium, and dehydration. In combination with low cortisol levels, patients in adrenal crisis may progress to shock, and death is not treated. The usual age of presentation is 1 to 2 weeks of age. Initial laboratory studies would include serum electrolytes, renin, cortisol and cortisol precursors, androgens, and glucose levels. Note that low cortisol will also impact gluconeogenesis and glycogenolysis. This diagnosis would be less likely in a non-viralized female. B. Symptoms of hypoglycemia in the neonate may include jitteriness, tremors, hypotonia, poor feeding and seizures. Management includes STAT glucose levels and intervention with parenteral or oral glucose, as indicated. The work up will include laboratory studies to rule out hyperinsulinism (IDM, insulinoma, prematurity), increased metabolic demand (polycythemia, sepsis, asphyxia), and inborn errors of metabolism (galactosemia, glycogen storage diseases, maple syrup urine disease). This patient did not present with jitteriness, tremors, or seizures. C. Sepsis should always be considered in lethargic neonates. While septic infants may present with fever or hypothermia, they may also be afebrile. This child did not appear to be acutely ill or toxic in appearance. D. Congenital hypothyroidism may present with poor feeding, constipation, jaundice (longer and more persistent than physiologic jaundice of newborn), mottled skin, large fontanels, hypotonia, hypothermia and an umbilical hernia. Later findings include a hoarse cry, macroglossia, and myxedematous facies. Patients usually remain asymptomatic until after 6 weeks of age, as maternal thyroid hormones may still be in younger infants. Patients with primary hypothyroidism will have high TSH and low T4 levels. The most common cause of primary hypothyroidism will be aplasia or hypoplasia of the thyroid gland, and—much less commonly—inborn errors of metabolism. Secondary or tertiary hypothyroidism (HPA dysfunction) will have both low TSH and low T4, and are relatively rare causes of hypothyroidism in infants.

Immunizations at 2 months

DTaP (4 total), Hib (3/4 total), IPV (4 total), PCV13 (4 total), RotaV (2 total), 2nd hep B

Risk factors for acute otitis media (11)

Daycare attendance Tobacco exposure Allergies Bottle propping at bedtime Pacifier use Drinking formula from a bottle rather than BF Significant family history of AOM Male gender Lower socioeconomic status Respiratory allergies

Maternal Benefits of breastfeeding

Decreased risk of: - Breast cancer - Ovarian cancer - Osteoporosis

Brief resolved unexplained event definition, sxs

Def: event occurring in infant <1 year when observer reports a sudden, brief, and resolved episode that includes 1+: 1. cyanosis or pallor 2. absent, decreased, or irregular breathing 3. marked change in tone (hyper- or hypotonia) 4. altered level of responsiveness. - used to define events only when no underlying etiology is found - dx of exclusion. - pt must have reassuring hx, PE, and vital signs at time of evaluation.

Occult bacteremia

Def: when there is a positive blood culture in a well-appearing child. - most children with occult bacteremia will NOT develop a serious bacterial illness (SBI), whereas a child with sepsis represents a medical emergency.

Essential screening test for patient with suspected hypertrophic cardimyopathy

ECG (detects up to 90%)

What skin disease presents with IBD?

Erythema nodosum

Honeymoon phase after dx of T1DM

In the one month after dx, little need for insulin. But does not mean patient is cured.

Physiology of VSD

L to R shunt of blood during ventricular systole causes increased pulmonary blood flow --> increased pulmonary venous return -> LV volume overload. - magnitude of shunt is dependent upon size of defect and the relationship between systemic and pulmonary vascular resistance.H

hepatic tumor labs

LFTs usually normal, liver enzymes and bilirubian may be elevated in 20% of cases. AFP levels will be increased in most patients.

Rosacea

More often seen in adults. "Early" form seen in adolescents is characterized by inflammatory papules and micropustules, and redness. - NO COMEDONES - Worsens with alcohol, spicy food, temperature extremes, and stress. - Tx: topical metronidazole + others

Most common cause of chest pain in a pediatric patient

Msk

Do you perform a rapid strep test or throat culture in a patient <2yrs?

NO

Do all kids with fever be seen in the ED immediately?

NO. Exception: infants < 6-8 weeks of age

Most common urea cycle disorder

Ornithine transcarbamylase deficiency

Intussiception incidence

Overall: 1-4 cases per 1,000 live births 80% of cases occur in children < 2 Boys are affected more often than girls

In which infants are umbilical hernias more common?

Premature Congenital hypothyroidism

Erythema infectiosum rash

Rash starts on face with a "slapped"-cheek appearance followed by a reticular (lacy) erythematous rash on the trunk and extremities. Caused by parvovirus B19.

How we historically decreased hyperbilirubinemia in children?

Rh screening

18 month old speech

Should be saying at least 6 words

Obesity complications

Sleep apnea, dyslipidemia (high TG, low HDL) , HTN, slipped capital femoral epiphysis, T2DM, steatohepatitis

Most common hip d/o in adolescents

Slipped capital femoral epiphysis

Cerebral palsy types (5)

Spastic: tense*** Athetoid: uncontrolled Ataxic: balance Rigidity: tight muscles Tremor: shaking

Bordetella Pertussis course

Triphasic 1. catarrhal stage: lasts 1-2 weeks, GET upper respiratory tract infection sxs. 2. Paroxysmal stage: lasts 4-6 weeks GET repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in characteristic "whoop." Infants generally do not develop a "whoop" due to relative weakness of their inspiratory effort. 3.Convalescent stage: Paroxysms of cough gradually decrease in frequency and severity. Episodic cough may persist for months.

What supplementation is recommended in exclusively breast fed babies?

Vitamin D

Vitamin D deficiency rickets

Vitamin D deficiency rickets generally appears between 6-24 months and responds to tx with vitamin D.

Cough that is worse at night

asthma

A child with symptoms of asthma who responds to therapy for asthma and has no other identifiable cause for wheezing has...

asthma (regardless of age)

appendiceal abscess sxs

abd pain, fever, nausea, anorexia

What does bilirubin bind to?

albumin

radioallergosorbent test (RAST)

blood test used to determine to which allergens a person is sensitized

CF false positives

can occur with a # of metabolic disorders like adrenal insufficiency and hypothyroidism.

Bilirubin pathway in infant

cannot metabolize bile where conjugated bilirubin is, so b glucorunidase present in meconium hydrolyzes it back to unconjugated form .

Important causes of injury in a toddler

car accidents swimming pools falls firearms poisonings fires

NF1

café au lait macules neurofibromas optic gliomas lisch nodules HTN 2/2 vascular formations

Suggested immunizations for children with SCD

conjugated immunization better 13 1) Pneumococcal Vaccine - 13-valent pneumococcal conjugate vaccine given in first year of life provides protection against 13 serotypes contained in the vaccine. - To expand antibody coverage beyond 13 initial serotypes, children with sickling disorders receive 23-valent pneumococcal polysaccharide vaccine at ***2 and 5 years of age. 2) Meningococcal Vaccine - Children with anatomic or functional asplenia should also receive meningococcal conjugate vaccine at age ***2 years. Will receive a booster dose 3-5 years later. 3) Influenza vaccine annually, children with sickle cell disease are at higher risk and should be immunized against this also.

PDA murmur

continuous, but a bit louder in systole.

Barking cough causes (3)

croup subglottic disease foreign body

First line tx for Crohn's

mesalamine

Dry cough causes (3)

environmental irritant asthma fungal infection

What are soft tissue neck films used for?

evaluation of supra glottal or sub glottic anomaly

Brudzinski's sign

flexion of the hip and knee in response to flexion of the neck by the examiner

Crohn's abnormal labs

guaiac-positive stool anemia high plt count high ESR hypoalbuminemia

Cough that disappears at night

habitual cough

Brassy or honking cough (2)

habitual cough tracheitis

most commonly aspirated foods

hot dogs, hard candy, nuts, grapes, and popcorn.

What is jaundice associated with?

hyperbilirubinemia

Neuroblastoma imaging and lab

imaging: ct shows calcifications, heterogenous mass wti hcystic areas labs: path small round blue cells (small cell rosettes) with hyperchromatic nuclei and scant cytoplasm; urinary HVA/VMA, CBC with anemia or cytopenia secondary to bone marrow infiltration

HA that awakens from sleep

increased ICP

High reticulocyte count

increased destruction or blood loss

common organisms for atypical pneumonia (3)

influenza adenovirus mycoplasma other organisms to consider include pertussis, HIV, and fungal.

What to recommend to kids receiving long term aspirin therapy

influenza vaccination to prevent reye syndrome

Signs of severe dehydration

lethargy or unconsciousness on exam poor PO intake tachycardia weak or nonpalpable pulses deep breathing deeply sunken eyes parched mouth and tongue reduced skin turgor cold/cyanotic extremities

What cancer causes splenomegaly

leukemia

Atonic seizure

loss of motor tone

Kernicterus signs

loss of suck reflex lethargy hyperirritability sz death

Fever in SCD kid is a...

medical emergency!!!!!!!

When should gestational age assessment be done in a neonate?

on every neonate within 12-24 hours of life.

When can you get a urine culture in a neonate?

only after 4 days

Kernicterus sequelae if survive

opisthotonus rigidity oculomotor paralysis tremors hearing loss ataxia

A diastolic murmur is always...

pathologic

First sign of hypoalbuminemia?

periorbital edema

Paroxysmal cough (4)

pertussis chlamydia mycoplasma foreign body

Most common cause of ataxia in children

post infectious cerebellitis

Oral rehydration therapy is good for which population?

pts with mild to moderate dehydration

Is NG lavage for OD ingestion helpful?

Nope

Labs in nephrotic syndrome

1) Hypoalbuminemia 2) Hyperlipidemia

Bicuspid aortic valve

- Common heart abnormality. - If bicuspid valve: not stenotic or regurgitant, then there will be no murmur. - Get: early systolic click shortly after S1 made by the abnormal valve when it opens . Usually detect this early in childhood.

papular urticaria

- Common pediatric condition. - Lesions are papular and 3-10 mm in diameter. - by insect bites. - recurrent or chronic. - Pruritic.

Roseola

- Common viral illness in children < 2 years - HHV-6 - High fever is often only symptom in first few days of illness and typically lasts for 3 to 5 days. - Some develop a rash for 1-4 days as fever resolves - Tx: reassurance

Anticholinergic drug OD symptoms

(Diphenhydramine, tricyclic antidepressants) - Mydriasis (dilated pupils) "blind as a bat" - Dry skin "dry as a bone" - Red skin (flushed) "red as a beet" - Fever "hot as Hades" - Delirium and seizures "mad as a hatter" - Tachycardia - Urinary retention - Ileus

Isotonic/Isonatremic dehydration

(Na = 130-150 mEq/L [130-150 mmol/L]) - most common type of dehydration in children - when sodium and water losses are balanced - ex: acute gastroenteritis and diarrhea. - deficit in isonatremic dehydration can be replaced over 12 hours.

Hypertonic/Hypernatremic dehydration

(Na > 150 mEq/L [> 150 mmol/L]) - when water losses exceed that of sodium and is associated with the highest mortality. •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.

Holosystolic murmur

(VSD) MR Tricuspid regurgitation

Nummular eczema

- Consists of coin-shaped lesions commonly on legs and buttocks. - annular configuration and scaly appearance like tinea.

Seizures in a newborn

- Often subtle - jerking or horizontal deviation of the eyes; blinking or fluttering of the eyelids; drooling, sucking, or lip smacking; tonic posturing of a limb; or apnea.

A 10-month-old infant is brought to the Peds ED by her parents, who say she has been coughing persistently for the last three hours. The parents were watching a movie at home when they first noticed their daughter coughing. Patient is a vaccinated, well-nourished infant in moderate distress with retractions, nasal flaring, and grunting. On auscultation, you immediately notice diminished breath sounds in the right lung with normal breath sounds on the left. What other associated physical exam finding do you expect to hear? A Stridor B Asymmetric breath sounds and wheezing C Rhonchi D Crackles E Bronchial breath sounds

*****B. This infant is in respiratory distress from foreign body aspiration, consistent with the history of acute onset of distress and asymmetric breath sounds. Respiratory distress from foreign body aspiration is usually accompanied by asymmetric breath sounds and wheezes on auscultation. C. Rhonchi are coarse, low-pitched, rattling sounds due to secretions and airway narrowing and are typically heard in the setting of bronchitis or pneumonia. D. Crackles are due to fluid in alveoli or opening and closing of stiff alveoli, not consistent with a foreign body aspiration. You would expect this in either pneumonia or CHF from pulmonary edema, both of which are unlikely in this patient given abrupt onset and lack of history of cardiac problems. E. Bronchial breath sounds are hollow-sounding and caused by air moving through areas of consolidated lung, such as in the setting of pneumonia.

A mother brings her 8-year-old son to his primary care physician for pain in his knees and ankles that have been present for the past three days. She also notes that he has had a rash since yesterday, but otherwise feels well. The patient has no chronic illnesses, but he was brought in three weeks ago for an upper respiratory infection. Exam is significant for pain elicited on passive movement of the ankles and knees. Additionally, the patient is found to have an erythematous, slightly raised, non-blanching, maculopapular rash over the legs, buttocks, and posterior portion of the elbows. CBC shows WBC 8.9, Hgb 12.5, Hct 36.1, and Plt 327. Urinalysis is unremarkable. Skin biopsy shows leukocytoclastic vasculitis with IgA deposition. Which of the following is the best next step in management? A Observation B Corticosteroids C Intravenous immunoglobulin (IVIG) D Intravenous hydration E Platelet transfusion

****A . The joint pain, purpuric rash, and IgA deposition on skin biopsy support the diagnosis of HSP. Most cases of HSP resolve within approximately one month and do not require treatment. However, symptomatic treatment for joint pain, initially with NSAIDs, may be indicated. B. Corticosteroids can be useful as a second line agent for treating joint pain. Additionally, corticosteroids can be used as part of an immunosuppressive regimen in HSP patients who have acute kidney failure. There is no suggestion of kidney involvement in this case, and urinalysis was found to be unremarkable. Note that steroids may also be used in HSP patients with severe abdominal pain, but this patient did not present this way.

A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (dropped from 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests? A Chest x-ray and tuberculin skin test B CT of nasal sinuses C Spirometry, before and after bronchodilator therapy D Chest x-ray and methacholine challenge E None needed, patient likely has habitual cough

****A. CXR and tuberculin skin test (TST) is the best choice. Toddlers may present with nonproductive cough, mild dyspnea, wheezing, and/or failure to thrive (weight < 5th percentile or drop in two percentile curves for weight). In children, TB can present without systemic complaints (fever, night sweats, and anorexia), severe cough, and sputum production. Regarding diagnostic tests, the TST is a practical tool for diagnosing TB infections. All children with chronic cough (more than three weeks) should be evaluated with a chest x-ray, as other pathology—such as lung abscess or malignancy—can also be detected on CXR. B. Sinusitis is often preceded by a URI, with nasal congestion as a prominent feature, leading to nocturnal cough due to post-nasal drip. These symptoms are not seen in our patient. Furthermore, a diagnosis of sinusitis is made clinically, with CT scan obtained only in complicated cases or cases resistant to treatment. Complications include cavernous sinus thrombosis, meningitis, and epidural abscess. C. Spirometry (pulmonary function testing) before and after bronchodilator therapy is most specific means of determining whether or not a child has reactive airways. Asthma is a very common diagnosis in pediatrics, and may present with cough that is worse at night and exacerbated by exercise and cold air. Patients with cough-variant asthma present with only cough, typically nonproductive. However, given this patient's failure to thrive, a more serious diagnosis such as TB must be considered. Also, a chest x-ray is needed in all children with chronic cough (more than 3 weeks). D. Although a chest x-ray is appropriate in all children with chronic cough, a methacholine challenge (for asthma) would be inappropriate in this scenario. Although asthma is a common diagnosis, given the patient's failure to thrive, a more serious diagnosis must be considered. Further, a methacholine challenge is reserved for cases in which asthma is suspected and spirometry is normal or near normal, and should be performed by trained individuals. E. Habitual cough is caused by habitual perpetuation of a cough that begins with a viral URI. Continued coughing further irritates the airway, leading to stronger stimulation to cough. The cough is typically very loud, short, dry, brassy, and spasmodic. This cough is unchanged by exercise or cold air, and classically resolves during sleep. Although the patient in this case has a dry cough, his failure to thrive points to a more serious diagnosis (e.g., TB). All children with chronic cough (persisting longer than three weeks) need a CXR.

You are working overnight call in the ED when Charlie, a 3-year-old male infant, arrives after his parents witnessed an episode of convulsions at home. His parents report that Charlie was in his usual state of good health until three days ago when he developed fever, cough, and rhinorrhea. This evening they found him in bed with his eyes rolled upward, jerking all four of his extremities uncontrollably. He was unarousable from this state, which self-resolved after about two minutes. This has never happened before. Currently, Charlie is sleepy but arousable and complains of nausea. His vitals include T 103.2 F, P 112 bpm, BP 100/60 mmHg, RR 22 bpm, O2 sat 99% on room air. Aside from rhinorrhea and erythematous mucous membranes, the remainder of his physical exam is unremarkable. What is the next best step in management? A Workup for source of fever B EEG C MRI brain D Abdominal ultrasound E Administration of valproic acid

****A. Charlie has likely experienced a febrile seizure in setting of an infection. These are relatively common occurrences in Charlie's age range (6 months to 5 years), and first priority would be to identify the source of fever and treat it. B. This answer is incorrect because EEGs are indicated in recurrent, focal, or complex seizures. An EEG may eventually be useful to evaluate Charlie's situation, especially if he has another seizure in the ED or if his febrile seizures recur in the future; however, identification of the source of the fever should be the first priority. In addition, interictal EEGs are only positive in 60% of children with epilepsy. C. This answer is incorrect. In differential diagnosis of a self-limited generalized seizure in setting of fever in a child of this age group, a febrile seizure is higher on differential than a brain mass. D. This answer is incorrect. Acute abdomen is low in differential in setting of presenting symptoms of cough, rhinorrhea, and fever. E. This answer is incorrect, because majority of patients with febrile seizures do not require treatment with anticonvulsants. This is especially true if this is Charlie's first febrile seizure. Anticonvulsants such as phenobarbital or valproic acid may rarely be indicated, but generally these drugs are not recommended in the setting of febrile seizures because they are associated with serious side effects.

An 11-year-old male comes to clinic with a chief complaint of abdominal pain for three months. The pain is not associated with eating. Sometimes he feels full and nauseated, along with pain, but then it resolves on its own. He denies diarrhea, vomiting, and bloody stools. His mother is primarily concerned because his abdominal pains cause him to miss school quite often now. ROS is otherwise negative and the only pertinent issue is his pain. When you evaluate his growth curves, he is progressing at the 60th percentile for height and weight and you do not notice a change since birth. Through a social history you ascertain that he is quite intelligent and has recently been advanced to 7th grade from 5th grade. Vital signs are within normal limits for his age and physical exam (including rectal and genital) are unremarkable. Stool sample was sent in anticipation of today's visit and was negative for occult blood. What is the most likely cause for his abdominal pain? A Functional abdominal pain B Inflammatory bowel disease C Bacterial gastroenteritis D Peptic ulcer disease E Meckel's diverticulum

****A. Functional abdominal pain would be most likely diagnosis in this setting at this time. History in this setting is not suggestive of any other diagnosis directly causing his abdominal pain, except a change in his social setting. For better understanding of the nature of this child's pain, it would be best to talk to him alone, without his mother present, to determine if he is having trouble adjusting to school and to assess whether he has a stable home environment. His pain is chronic, with no other symptoms (diarrhea, bloody stools, growth failure), making a functional issue most likely. B. Inflammatory bowel disease (Crohn's disease or UC) could be the cause of this child's pain, but more frequently IBD presents with growth failure, diarrhea, bloody stools, and sometimes fever. Although this could be an early presentation, the absence of arthritis, uveitis, and other constitutional symptoms, make IBD less likely. C. Choice C is incorrect because bacterial gastroenteritis is more of an acute issue and would be unlikely to persist for months. The absence of diarrhea also suggests bacterial gastroenteritis is not the best answer option. D. Choice D is incorrect because peptic ulcer disease (PUD) is relatively uncommon in children and the stool sample was negative for occult blood. PUD would be chronic and recurrent, but should also be associated with eating and would not spontaneously remit every couple of days. E. Choice E is incorrect because Meckel's diverticulum usually presents as painless blood in the stool.

Steven, a 5-year-old boy with no significant past medical history, was in his usual state of health until last night when he developed abdominal pain. This morning his mother noticed a red and blotchy rash on his buttocks and lower extremities and his abdominal pain has worsened. Otherwise, he has no other symptoms and except for an upper respiratory tract infection last week, he has been in good health recently. On exam, the presence of palpable purpura and petechiae over the buttocks is confirmed. Laboratory studies are normal and, after a clinical diagnosis is made, he is discharged home the same day and given instructions to return for follow-up. Which of the following is important to measure at the first follow-up visit? A BP and urinalysis B Platelet count C PT/PTT D White blood cells and hemoglobin E Signs of intracranial hemorrhage

****A. Henoch-Schonlein Purpura (HSP). The exact etiology of HSP is unknown, but it is believed to involve an IgA-mediated immune response to infection or other triggers. incidence is 10 cases per 100,000 children with a peak at ages 4-6 years (range of 2 to 17 years). HSP is characterized by a rash consisting of petechiae and palpable purpura. Other findings include a colicky diffuse or periumbilical abdominal pain, arthritis or arthralgia, and renal disease. Given incidence of renal disease, it is important to check the urine for signs of hematuria or proteinuria; sudden changes in blood pressure can potentially suggest a change in renal function. With abnormal findings, serum BUN and creatinine must be checked. B. Platelet count is normal in HSP since the hallmark rash is a non-thrombocytopenic purpura. Idiopathic thrombocytopenic purpura (ITP) is part of the differential for palpable purpura and petechiae. ITP is characterized by low platelet counts (usually < 20,000) with normal WBCs and hemoglobin. Should you find low platelets, you may want to reconsider the differential and think about ITP or possibly leukemia. C. A coagulation disorder is part of the initial differential for a patient presenting with palpable purpura and petechiae. In this case, our patient with HSP has no abnormalities in any coagulation pathway. Instead, the mechanism of petechiae and purpura is secondary to an immune-mediated vasculitis. Therefore, checking the PT/PTT at the first follow-up visit is not indicated in this case. D. Leukemia was in the initial differential for Steven's petechiae and purpura rash. Leukemia is characterized by abnormalities in the different cell lines (WBC, RBCs and platelets) resulting in cytopenias. The clinical presentation of leukemia is associated with bone marrow infiltration and cytopenia. Signs and symptoms include petechia and purpura, bone pain, fever, fatigue, malaise, hepatosplenomegaly, and lymphadenopathy. When leukemia is suspected, it is important to measure WBCs, Hgb and platelets. In HSP, there should not be any abnormalities in any of these cell lines and, therefore, measuring these values at follow-up does not contribute any significant information. E. ICH is a potential but rare complication of idiopathic thrombocytopenic purpura (ITP). The incidence of ICH in patients with ITP is 0.1 to 0.5% of cases. In this case of HSP, ICH is not a potential complication.

A 6-year-old male comes to the clinic with a chief complaint of scrotal swelling, recent weight gain, and decreased appetite. Vital signs are stable and there is no evidence of cardiac disease or jaundice. Further workup reveals proteinuria, hypoalbuminemia, and hyperlipidemia, consistent with nephrotic syndrome. Which of the following histological patterns is most likely to be seen on light microscopy? A Normal glomeruli with minimal increase in mesangial cells and matrix B Mostly normal glomeruli and mesangial proliferation but with areas of juxtamedullar glomeruli showing segmental scarring in one or more lobules C Tram-track appearance of glomerular basement membrane and subendothelial immune complex deposition D Enlarged, hypercellular glomeruli with neutrophil invasion E Glomeruli showing diffuse capillary and glomerular basement thickening

****A. This choice is correct because it describes the histology seen in minimal change disease; most likely diagnosis of nephrotic syndrome between the ages of 1 and 10 years old, accounting for up to 85% of cases. B.Focal segmental glomerulonephritis (FSGS). Segmental sclerosis and scarring as well as hyalinosis can be seen on light microscopy in FSGS. ~ 10% of cases of nephrotic syndrome in children. Over time, FSGS can often lead to involvement of all glomeruli and can lead to ESRD C. Membranoproliferative glomerulonephritis (MPGN). MPGN accounts for less than 5% of cases of nephrotic syndrome in children. D. Acute post-streptococcal glomerulonephritis, which is a cause of nephritic syndrome, not nephrotic syndrome. Nephritic syndrome is an inflammatory process leading to hematuria and RBCs in the urine. Nephritic syndrome is associated with azotemia, oliguria, hypertension, and less severe proteinuria (< 3.5 g/day). E. Diffuse membranous glomerulonephritis.

A 5-year old previously healthy boy is brought to his pediatrician with complaints of intermittent abdominal pain, right ankle pain, and a purpuric rash over his buttocks and lower extremities. His mom says she thinks he may recently have recovered from an upper respiratory infection. Which of the following statements is true? A CBC would likely reveal thrombocytopenia B This disease is classified as a small vessel vasculitis C Urinalysis is not warranted for this patient's work-up D Treatment options include IVIG E This disease is equally common in girls and boys

****B. Choice B is correct because HSP is classified as a small vessel vasculitis. The exact mechanism of HSP is unknown; however, it is thought to be an IgA-mediated immune response affecting small vessels (skin, GI tract, joints, kidneys). Approximately 50% of cases follow viral or bacterial URIs. Biopsy of affected organs shows leukocytoclastic vasculitis with IgA deposition. C. Choice C is incorrect because 20 to 50% of individuals with HSP have renal involvement, so UA would be an appropriate study to order in a suspected HSP case. UA will often reveal mild hematuria and/or proteinuria. If either are present, BUN and Cr should be ordered to further evaluate the extent of renal involvement. D. Choice D is incorrect because treatment of HSP is symptomatic and supportive (e.g., NSAIDs for joint pain). HSP usually resolves within 4-6 weeks and has a 30% recurrence rate. IVIG is not indicated in patients with HSP; it is, however, a treatment option for ITP. E. Choice E is incorrect because HSP occurs in children ages 2 to 17 years, with the majority occurring between ages 4 and 6. Boys are affected twice as often as girls.

An 18-month-old presents with yellow and poorly mobile tympanic membranes. Four months prior he presented then with several days of nasal congestion, cough, decreased eating and ear tugging. His exam then revealed a red, nonmobile tympanic membrane and he was treated with amoxicillin. Based on the history and physical exam, what is the most likely diagnosis now? A Mastoiditis B Acute otitis media C Otitis media with effusion D Otitis externa E Viral encephalitis

****C. The earlier diagnosis of acute otitis media together with current findings of bilateral yellow and poorly mobile tympanic membranes on physical exam make this most likely diagnosis. D. Although otitis externa presents with otalgia, signs of bilateral yellow and poorly mobile tympanic membranes are more suggestive of otitis media with effusion. E. Viral encephalitis typically causes neurologic dysfunction with signs that include fever, headache, nausea, vomiting, photophobia, altered level of consciousness, seizures, and possibly focal neurologic signs. This child's presentation is much more consistent with otitis media with effusion.

An 18-month-old male comes to clinic for a WCC. His mother says he is a happy boy and endorses no complaints. She notes that he was born a few weeks early via emergency C-section and spent two months in NICU. Feeding well and gaining weight. When you ask about developmental milestones, you find out that that he pulls himself up to stand, but is not walking yet. He has several words and is interactive. There is no family history of disease during infancy. He is up to date on his immunizations. He is one of five children and his parents are currently experiencing difficult financial times. Exam reveals increased tone and hyperreflexia in his lower extremities. What is the most likely diagnosis of his developmental delay (if any)? A Cerebral palsy B Normal variant C Metabolic disorder D Genetic abnormality E Psychosocial stress reaction

***A. Children with cerebral palsy often present with defects in motor development and are often found to have abnormal neuromuscular exams, including increased tone and reflexes. Other areas of development are less consistently impacted. The cerebral palsy most likely was result of an hypoxic injury during perinatal period. C. This choice is incorrect because this child's newborn screening exam was normal, he has no family history of metabolic disease, and has not had any indication of any metabolic abnormalities. D. This choice is incorrect because of a lack any characteristic syndromic phenotype and negative family history, and the delay appears to be limited to his gross motor exam. E. This choice is incorrect because of his persistence of developmental delay and lack of behavioral changes (temper tantrum, sleep disturbance, etc.). Temporary loss of developmental achievements can be seen in times of stress.

CI of IO

- Osteogenesis imperfecta - Fractured bone - Bone recently used for IO - Bone with overlying area of cellulitis, infection, or burn

A 16-year-old female presents with acute onset of diffuse abdominal pain with periodic sharpness in right upper quadrant that radiates to her back. She has had some episodes of vomiting and has a fever. She is sexually active and has used alcohol in the past. Which of the following is most likely to present with right upper quadrant pain? A Pancreatitis B Urinary tract infection C Ectopic pregnancy D Appendicitis E Ovarian torsion

***A. Choice A is correct because pancreatitis commonly causes continuous abdominal pain that can localize to right and left upper quadrants ("band-like pain") as well as radiating to back. Nausea and vomiting are nearly always present. Lipase is the most sensitive and specific lab test to diagnose pancreatitis. B. Choice B is incorrect because urinary tract infections classically cause painful urination with frequency and urgency. Patients may present with suprapubic tenderness, and flank pain is common when infection has spread to the kidney. UTIs are common in sexually active females, and fever and vomiting are often seen with pyelonephritis, but sharp RUQ would not be expected. C. Choice C is incorrect because although ectopic pregnancy is always a concern in a sexually active female presenting with abdominal pain, pain is typically located in the lower abdomen. Fever and diffuse abdominal pain are uncommon in uncomplicated ectopic pregnancy. D. Choice D is incorrect because appendicitis classically starts as periumbilical pain that migrates to McBurney's point (1-2" from the anterior superior iliac spine toward the umbilicus). It is also of concern in a teenager with a presentation like this, as acute appendicitis is most common pediatric condition requiring emergency surgery. Of children presenting with acute abdominal pain, 1-4% have appendicitis. E. Choice E is incorrect. Although ovarian torsion is possible at any age, abdominal pain is typically described as stabbing and is usually localized to the lower abdomen and pelvis. Nausea and vomiting can also be present.

You see a 6-year-old male in the ED who presents with a history of a 10-second episode of jerking movements of his extremities with unresponsiveness, observed by both of his parents. His parents claim he has had abdominal pain and small quantities of bloody diarrhea for two days. The child has no significant past medical history, has taken no medications recently, has no pets, and has not traveled outside of California in the past year. He attends kindergarten. Which organism is the most likely cause of the child's symptoms? A Shigella sonnei B Rotavirus C Clostridium difficile D Enterotoxigenic E. coli (ETEC) E Vibrio cholerae

***A. Shigella sonnei causes bloody diarrhea and WBCs in stool on Wright stain. Rarely, children infected with Shigella can suffer from seizures due to neurotoxin release. B. Rotavirus is most common cause of infectious gastroenteritis. It is an RNA virus that does not cause WBCs to appear in stool, and typically does not cause bloody diarrhea. Diagnosis is made using ELISA. Rotavirus is not associated with seizures. C. Clostridium difficile typically causes diarrhea after antibiotic use, which allows organism to overgrow normal intestinal flora. Would not be expected to cause diarrhea in an otherwise healthy child who is not taking any medications. Infection can be diagnosed by the presence of C. difficile toxin in the stool. D. ETEC is strain of E. coli that commonly causes traveler's diarrhea, a noninvasive infection without WBCs in the stool. Diarrhea is typically watery and contains no blood. E. Vibrio cholerae causes massive quantities of watery diarrhea, and patients may present with severe dehydration. Bloody diarrhea would not be expected. It is typically seen in endemic or epidemic form in developing countries, and would not be expected in a child living in the U.S. with no recent travel history.

A 7-year-old boy presents with a five-year history of intermittent vomiting, vertigo, and throbbing unilateral headaches that seem to be induced by emotional stress and when his teacher wears perfume. He reports that the pain is not worsened by long naps or coughing. His mother reports that she has a history of headaches that started as a child and wonders if her son inherited this from her. His neurological exam shows no focal deficits. What is the next step in diagnosis or treatment? A Trial of prophylactic medication for migraine headaches B MRI C NSAIDs D Referral to an ENT surgeon

***A. This child is presenting with signs of both typical and atypical migraines and could be started on a trial of prophylactic medication. Tricyclic antidepressants (TCAs) are often used in children for migraine prophylaxis. B. An MRI would be indicated if an intracranial mass is suspected. An infratentorial mass, which could increase ICP. Might cause headaches in the morning after laying down, or also when valsalva'ing during a cough. An infratentorial mass can also compress the cerebellum and may cause ataxia, dysarthria, and nystagmus. A supratentorial mass is more likely to present with focal motor and sensory deficit. C. NSAIDs are often used for tension HA. Unlike migraines, however, tension headaches cause pain in a band-like pattern around head. D. While ENT doctors specialize in vertigo that is caused by inner ear pathology, it is likely that this patient's vertigo is due to an atypical migraine.

You are notified that a 10-day-old patient in your practice had a newborn hemoglobin screen positive for sickle cell disease. Pregnancy and delivery were uncomplicated. Mother is 19 years old and works as a nurses' assistant at a nursing home. When questioned, she says she remembers her grandmother died of chest pain and a lung infection. Which of the following should be ordered next for the baby? A Antibiotics B CBC C Chest x-ray D H. influenza type b vaccination E Transcranial Doppler

***A. This newborn has sickle cell disease. Her grandmother likely passed away from acute chest syndrome. Due to decreased splenic function and consequent decreased resistance to infection with encapsulated organisms (S. pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis), infants and young children with sickle cell disease are at increased risk for sepsis. When given to infants with sickling disorders, penicillin significantly decreases risk of mortality from overwhelming sepsis. Prophylaxis is usually continued until child is 5-6 six years of age (after this, there is little data to support its use except in patients who have had documented sepsis and bacteremia, or who have had their spleens removed). B. A CBC is not warranted immediately in the absence of symptoms of infection in a newborn. C. A chest x-ray is not indicated in this infant with no respiratory symptoms. D. Vaccination against H influenzae and S pneumoniae (with 13-valent conjugate vaccine Prevnar 13) is indicated at 2, 4, and 6 months of age. Meningococcal vaccine is indicated at 2 years of age for patients with functional asplenia, with a booster at 5-6 years of age. The 23-valent pneumococcal polysaccharide vaccine is indicated at 2 years and between 5 and 8 years of age. This infant is too young for administration of the Hib vaccine. E. A transcranial Doppler may be performed in patients with sickle cell disease to assess for stroke risk but is not indicated in an asymptomatic newborn.

A 3-year-old girl comes to the clinic with a limp and a slightly externally rotated right hip. Which of the following signs/symptoms would you expect in the history or exam if a diagnosis of transient synovitis were made? A History of a recent URI infection B High-grade fever C Iridocyclitis D Knee pain E ESR of 110 mm/hr

***A. Transient synovitis of the hip is associated with a low-grade fever and frequently occurs during or after a URI. Between 32% and 50% of children who present with transient synovitis had a recent upper respiratory tract infection. It is also important to remember that transient synovitis is a diagnosis of exclusion, and it is important to rule out other causes of hip pain that may require urgent intervention, such as septic arthritis. B. High-grade fever would be more concerning for osteomyelitis or septic arthritis, and would not be expected in transient synovitis (although low-grade fever is possible). However, fever occurs in only half of cases of osteomyelitis. Other symptoms associated with osteomyelitis include localized bony tenderness, indolent presentation, and refusal to bear weight. Osteomyelitis cannot be ruled out due to absence of fever. C. Iridocyclitis is associated = juvenile idiopathic arthritis (JIA). Other findings associated with JIA include fever and rash. Diagnostic criteria for JIA include children <16 years old and at least 6 weeks of arthritis in at least one joint. D. can present as knee pain. However, it is not something that you would use to rule in or rule out transient synovitis (it is not specific for transient synovitis). E. A significantly elevated ESR would be concerning for septic arthritis. In fact, in one study, an ESR > 40 mm/hr was one of the criteria found to be more associated with septic arthritis than with transient synovitis. Other criteria associated more with septic arthritis than with transient synovitis include: refusal to bear weight, erythema, warmth, swelling, elevated CRP, and an elevated WBC count.

When you are at your preceptor's office, you are told to see Amy, a 20-month-old female diagnosed with cerebral palsy (CP) at the last visit. Your preceptor knows that you just had your lecture on CP and tries to have you figure out which type of CP Amy has. She tells you that Amy was born at full term but had severe jaundice and required extensive tx for hyperbilirubinemia, including exchange transfusion. She now has slow and uncontrolled mts throughout her body. Her brain MRI shows some atrophy of basal ganglia. What type of CP does Amy have? A Dyskinetic cerebral palsy B Spastic diplegia C Spastic quadriplegia D Spastic hemiplegia E Ataxic cerebral palsy

***A. choice is correct because dyskinetic CP is 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. B. Spastic diplegia is classically associated with premature birth and specific MRI findings of periventricular white matter abnormalities. Patients present with motor involvement that is more prominent in the legs than the arms. C. Patients with spastic quadiplegia have spasticity, clonus, and exaggerated tendon jerks throughout bodies. Imaging would show global brain abnormalities. D. spastic hemiplegia—associated with a stroke damaging a unilateral upper motor neuron tract—should present with spasticity of the contralateral arm and leg, not the entire body. E. ataxic cerebral palsy should show cerebellar abnormalities on imaging, while Amy's MRI shows only basal ganglia involvement.

Susie is a 3-year-old girl brought into the clinic by her mother because she has a gradually worsening cough and she has been having trouble breathing. Her mother says Susie sounds like she is barking when she coughs. Susie is up to date with her vaccinations. Susie's mom always watches her when she's playing. On physical exam, you note that Susie has inspiratory stridor. She does not have wheezing, there are no retractions, and she has symmetrical breath sounds. No pseudomembranes are appreciated on physical exam. What is Susie's most likely diagnosis? A Epiglottis B Croup (laryngotracheobronchitis) C Pertussis D Pneumonia E Foreign body aspiration

***B. Croup or laryngotracheobronchitis is due to a viral infection (Parainfluenza type 1). It is most common in the winter, and often occurs in children age 2 to 5 years. Croup can lead to non-specific URI symptoms with some degree of airway obstruction. A barky or seal-like cough and inspiratory stridor (which should be differentiated from expiratory wheezes) is common in croup. D. While retractions and cough are present with pneumonia, asymmetric breath sounds and tachypnea would be more specific for a diagnosis of pneumonia.

A 15-month-old is able to stand on his own, walk backward, and throw objects underhand. He is unable to draw/scribble or grasp markers. He can say one syllable words "ma" and "da" but his words are unintelligible. He holds a sippy cup with help. He does come when called, plays with a ball and waves bye-bye by imitating his parents. Does this baby have developmental delay, and, if so, within which domains? A Normal variant B Gross motor and fine motor delay C Fine motor and language delay D Language delay and gross motor E Social and language delay

***C. Correct. A 15-month-old child should be able to scribble, use a cup, and/or stack 2 blocks. His word count should be 3-6 words at this stage of development.

low reticulocyte count

- means decreased production Iron, folate, or B12 deficiency Lead toxicity Thalassemia Aplastic anemia Chronic inflammation Neoplasms TEC DBA Renal disease Hypothyroidis CDEA (congenital dyserythropoietic anemia) Sideroblastic anemia.

wilm's tumor

- median age 3 - 50% of pts get abd pain, vomiting - can be HTN - mass is smooth and does not cross midline

Breast milk jaundice timing

- middle of the first week of life (usually day 4 through 7) but may not reach its peak until se cond week.

Spastic diplegia

- premature birth*** - motor involvement, mainly in legs>arms - MRI findings: periventricular white matter abnormalities.

Red flags for Crohn's Disease

- Pain that: awakens child at night, localized - Involuntary WL or growth deceleration - Extraintestinal sxs: fever, rash, joint pain, aphthous ulcers, or dysuria - Sleepiness after attacks of pain - + FMH IBD (30% pts) - Abnormal labs: guaiac-positive stool, anemia, high plt count, high ESR, hypoalbuminemia - Abnormalities in bowel function:diarrhea, constipation, incontinence - Vomiting - Dysuria

Fluids Management in Septic Shock

- Critical goal: enhance perfusion - Often needs repeated boluses of fluid. Give as much fluid as is needed to attain perfusion. - After a certain point, you may need inotropes to enhance cardiac contractility and vasopressors to raise BP by vasoconstricting vessels. Epinephrine and dopamine are acceptable choices. A diuretic should be given only if the patient is well perfused and has signs of fluid overload (such as rales on the lung exam).

Medulloblastoma

- " infratentorial primitive neuroectodermal tumor" - most common pediatric brain tumor. - malignant tumor that may spread throughout CNS - capable of metastasizing to extracranial sites. - Tx: surgical resection, radiation, and chemotherapy. - Px dependent on size and dissemination of tumor.

When to seek ER care in a patient with SCD

- Fever - Splenic enlargement - Slurred speech - Chest pain - Rapid breathing - Increased pallor - Increased jaundice - Priapism

Wilm's tumor imaging

- ultrasound first to see if intrarenal - ct scan: heterogenous with areas of low density showing necrosis. - Lab: hematuria

Findings in acute chest syndrome

- Fever (80%) - Cough (62%) - Chest pain (44%) - Mean oxygen saturation (92%) - Developed ACS while hospitalized for other reasons (48%) - Specific cause identified (38%) (infection or pulmonary fat embolism) - Average hospital stay (10 days) - Of these patients, 3% died of ACS or other complications.

Viral syndrome (enterovirus) sxs

- Fever lasting 3-5 days (but not a prolonged high fever) - Non-descript rash (enteroviruses can cause rash on palms and soles) - Rash is not painful and should not cause refusal to walk

Palpebral Fissures

- Palpebral fissures elliptical openings of the open eyes, eye slits. - Down's: Upslanted palpebral fissures (medial aspect more superior than lateral) are a frequent finding in Down syndrome. - FAS: Short palpebral fissures

Post-infectious cerebellitis: epi, cause, dx, and course

- "acute cerebellar ataxia" - most common cause of acute ataxia in children (dx of exclusion in kids 1-3 yrs) - autoimmune response leading to cerebellar demyelination. - Not associated with fever or other systemic manifestations. - several weeks after viral infection (varicella or coxsackie virus). - Onset: sudden and consists of ataxia, vomiting, nystagmus in about half of patients and dysarthria in some. - CSF may be normal or have a pleocytosis; eventually CSF protein is elevated. - Majority of children recover completely within a few months.

Roseola rash

- "exanthem subitum" - starts on TRUNK and spreads to arms and neck. - less involvement of face and legs. - preceded by 3-4 days of high fevers, which end as rash appears. - Usually seen in children <two years old.

Demonstration of Primitive Reflexes

- Rooting - Sucking - Startle (Moro) - Palmar and Plantar Grasps - Asymmetrical Tonic Neck Response - Stepping Response

Rash associated with erythema infectiosum

- "fifth disease" - parvovirus B19. - Low-grade fever (37.8-38.3 degrees C, or 100-101 degrees F) - rash 7-10 days later. - rash starts as facial erythema-"slapped cheek" appearance. Can spread to the trunk and have an erythematous macular appearance. - Lacy, reticular appearance: central clearing of rash - rash lasts longest on extremities, - can also develop pain and swelling in joints (polyarthropathy syndrome). - Individuals with underlying immune deficiencies who are exposed to this virus are at risk for developing aplastic anemia.

Risk of recurrence of febrile seizures

-If a child has first febrile seizure <12 months, recurrence risk for a second febrile seizure is ~ 50%. - If a child has first febrile seizure after 12 months, recurrence risk is about 30%. - no long-term effects in terms of child development.

Barium studies in abdominal pain

-Important for evaluation of more chronic abdominal pain (IBD). - Also have a role in dx intussusception in younger pts w/ supportive hx and physical findings.

Failure to Thrive criteria

- "lack of physiologic growth and development" - When any of three situations occurs: a) Weight falls below the 3rd percentile b) Weight for height/length falls below the 3rd percentile c) Rate of weight gain slows compared with previous growth, crossing two or more major percentiles on growth chart in a downward direction.

CXR: Transient tachypnea of the newborn (TTN)

- "wet" looking lungs - no consolidation - no air bronchograms.

Common Infectious Complications of Nephrotic Syndrome (4) and how to prevent it

- ***Spontaneous peritonitis: insidious presentation of fever and minimal other findings; step pneumo most common. If untreated: can lead to overwhelming sepsis and death, especially while pts is on steroids. - Pneumonia - Cellulitis - Urinary tract infection Prevention - When in remission, patients should receive: a) Polyvalent pneumococcal vaccine b) Two doses of varicella vaccine (if not already immunized) c) annual influenza vaccine

Sepsis/bacteremia in an infant

- Fever usually—but not universally—present - young infants may present with HYPOTHERMIA - do not look well. - Early: elevated HR may be only vital sign abnormality. - LATE: send-organ hypoperfusion signs like poor perfusion (delayed capillary refill), low BP, AMS and other evidence of organ failure.

Meningitis symptoms

- Fever, HA, stiff neck, AMS, photophobia - BUT many pts present with only 2-3 sxs - In children, findings are less reliable and present in only about 50%.

Two month old infants development

- Fix and follow easily with eyes - Social smile - Strong suck - Coo. -Lie flexed at hips with good tone and move all 4 extremities well. - Lack good head control when held upright - Cannot roll over because of persistence of asymmetric tonic neck reflex. - When prone, can raise heads from side to side.

Management of Persistent Jaundice

- 1/3 of healthy breastfed infants can have persistent jaundice at 2 weeks of age. - For breast milk jaundice: jaundice may persist for up to 12 weeks. - Check for dark urine or acholic-appearing stools that might signify development of cholestasis. - Get total and direct bilirubin levels to be sure that direct bilirubin is not beginning to climb. - Increasing direct bilirubin would lead to a new diff dx that includes conditions such as biliary atresia and alpha-1 antitrypsin deficiency.

Fragile X

- 1/4,000 to 1/6,000 males. - difficult diagnosis to make in early childhood. - macroorchidism, usually documented after puberty. - Behavioral disturbances: such as hyperactivity, gaze avoidance, or autistic behavior-have been described.

Primary herpes simplex virus (HSV) gingivostomatitis

- 10 mos -3 yrs - ~10 to 30% of perioral HSV infections are symptomatic. - Fever and irritability may be initial symptoms, but oral lesions that start as vesicles and evolve to ulcerations are seen shortly after the onset of symptoms.

Holliday-Segar method for calculation of maintenance fluids

- 100 mL/kg/day for the first 10 kg of body weight - 50 mL/kg/day for the second 10 kg of body weight - 20 mL/kg/day for each additional 1 kg of body weight

Caloric Requirements of Infants

- 100-110 Cal/kg/24 hours in first 4 months of life. - Improperly prepared formula may be too concentrated or too dilute and result not only in excessive or inadequate calorie intake but also in electrolyte abnormalities

blood lead level testing recs

- 12 to 24 months of age in areas where > 25% of housing was built before 1960 or where prevalence of blood lead levels > 5 μg/dL in children is 5% or greater. - Individual children who live in or regularly visit homes/facilities built before 1960 that are in poor repair or have been renovated within past 6 months.

fingerstick hgb

- 12months for all children - at any age if risk factors

Hypoxic-ischemic encephalopathy

- AMS can be seen w/ hypoxic-ischemic encephalopathy, but would typically appear shortly after birth. - often have low APGAR scores. - often evidence of multi-system dysfunction (poor cardiac contractility, perfusion, renal insufficiency, seizures) early in the neonatal course.

Causes of Subdural Hematomas

- Abusive head trauma from violent shaking/ throwing (+ retinal hemorrhages, bridging vessels tear due to extreme rotational cranial acceleration force to brain and diffuse axonal injury to neurons) - Accidental trauma: MVA - Complication of delivery (vacuum extraction or forceps deliveries) - uncommon. Resolve within 4-6 weeks after birth. - NOT DUE TO CPR or sz or short falls <4 feet

single parenthood is a RF for..

- Accidental or non-accidental injury or poisoning - Failure to thrive - Behavioral difficulties.

Transient synovitis in children

- Acute onset of hip pain with no other constitutional sxs is typical - often occurs during or following a URI - low-grade fever sometimes (If fever was high, you would be concerned about possibility of septic arthritis.)

Pulmonary TB lung findings

- All lobar segments of lung are at equal risk of initial infection. - Two or more primary foci are present in 25% of cases. - common sequence: hilar adenopathy, focal hyperinflation and then atelectasis, with minimal evidence of primary lung focus itself. - Small local pleural effusions are common.

Parenteral Antibiotic Treatment of Pyelonephritis

- Ampicillin/gentamicin: a) Resistance rates of ampicillin to E. coli are rising, so ampicillin alone would not provide adequate coverage. Good for enterococci too. b) When combined with gentamicin—(excellent activity against coliforms)—it is a good option for treatment of pyelonephritis. - Ceftriaxone: excellent coverage against most gram-negative bacilli (except Pseudomonas) Not effective against enterococci. Excellent safety profile in children. Can be given once daily. Calcium-containing medications cannot be given through the same IV line as they may interact with ceftriaxone to form precipitates in lungs and kidneys

Clonus in a child

- Ankle clonus: hyperactive stretch reflex from an UMN lesion). Up to 10 beats should be considered normal in newborn period if no other neurologic signs are present and it is not distinctly asymmetric. - Clonus normally disappears rapidly - more than 3 beats in a child 1-2 months old is abnormal.

Treatment acute asthma exacerbation

- Anti-inflammatory therapy with corticosteroids - Bronchodilation with beta-2 agonists such as albuterol, together with supportive care for hypoxemia or dehydration.

Tx for sinusitis

- Antibiotic therapy - Additional observation (for 3 days) for those with persistent but not worsening course. - recommended first-line antibiotic tx for sinusitis is amoxicillin (with or without clavulanate). - Note: Results of cultures taken from the nose not recommended as a guide for therapy.

SGA vs IUGR

- SGA: diagnosed at time of birth. Depending on cutoff level used, up to 70% of SGA infants are small simply due to constitutional factors determined by maternal ethnicity, parity, weight or height. - IUGR: growth-restricted fetus, one that has not reached its growth potential at a given gestational age due to one or more causative factors. A fetus is noted to be IUGR *during* pregnancy.

APGAR score

- Appearance (skin color) - Pulse (heart rate) - Grimace (reflex irritability) - Activity (muscle tone) - Respiration A newborn receives a score of 0, 1, or 2 for each component, with the final Apgar score ranging from 0 to 10. **literature shows that 1-min Apgar score is less useful than 5minute score in predicting neonatal death. **Apgar score alone correlates poorly with future neurological outcome of the term infant.

Ependymomas

- Arise from within fourth ventricle (from ependymal lining) - cause symptoms related to hydrocephalus. -Tx: surgical resection, followed by radiation. - 5-year survival: 50%.

One complication of Lyme disease that occurs 4weeks after skin lesion

- Arthritis: second most common manifestation - large joints closest to the rash most commonly affected. - arthritis may relapse or occur only once.

First baby breath

- At delivery: infant's first breath results in replacement of lung fluid by air -> fluid leaves lungs by a being squeezed out during uterine contractions with vaginal delivery + absorption by pulmonary lymphatics. - Delayed absorption of pulmonary fluid --> TTN (persistent postnatal pulmonary edema.) - first physical examination of neonate provides a good indication of infant's successful transition to extrauterine life.

Intussusception in infant

- BILIOUS emesis - crampy or severe abdominal pain. - classic "currant jelly" stools of intussusception may be mis-identified in the history as diarrhea. - abdominal exam in children with intussusception often shows the presence of a "sausage-like" mass due to the telescoped bowel.

Treatment of Hypoglycemia, Hypotension, and Tachycardia

- Boluses of 20cc/kg NS and 25% D5. - Follow by administration of fluids with 10% dextrose at maintenance. It is critical to rapidly correct hypoglycemia and frequently reassess both blood sugar and BP to make sure the child is responding to the therapy

3 year old developmental milestones

- Brushes teeth (with assistance), Feeds self - Speaks in 2- to 3-word sentences, 75% understandable - Knows name and use of "cup, ball, spoon, crayon" - Builds tower of 6-8 cubes, Throws a ball overhand, Rides a tricycle, Copies a circle

CNS cause of altered mental status (5)

- Seizures - Tumor: Increased ICP due to mass effect from tumor can result in PROGRESSIVE behavioral changes and altered mental status. - SAH - Meningitis: increased ICP and decreased responsiveness. - Trauma: Child abuse and shaken baby syndrome -> intracranial bleeds -> signs from decreased alertness to complete unresponsiveness and deep coma.

Complement levels in nephrotic syndrome or glomerulonephritis

- C3 and C4: useful to determine if there is a secondary cause for nephrotic syndrome. - Levels decreased in GN or nephrotic syndrome due to: 1) collagen vascular disease:SLE (persists over 3 weeks) 2) 1ary renal disease other than MCD (membranoproliferative glomerulonephritis) 3) infectious etiology such as a recent group A strep infection (post streptococcal glomerulonephritis- will return to normal after 6-8wks).

Lab eval of abd pain and bloody stools (6)

- CBC - ESR - LFT - IgA TTG - O&P - Stool culture

Labs for evaluation of bleeding in patient

- CBC with plts, red blood cell indices, a smear - Reticulocyte count - pt, ptt - Platelet function test (which has largely replaced bleeding time in most centers) - Factor VIII activity - von Willebrand factor antigen - von Willebrand factor activity (also known as Ristocetin cofactor)

Complications associated with Kawasaki disease

- CNS manifestations (irritability, lethargy, aseptic meningitis): 90% - Coronary artery aneurysm (within 4 weeks of sxs): 20-25% of untreated patients - Liver dysfunction:40% Arthritis: 30% Hydrops of gallbladder- 10%

Coarctation of the aorta

- Can present in infancy or at any age beyond because it tends to be a progressive problem, gradually getting more severe over a period of years. - murmur - HTN in the upper extremities - discrepancy between upper and lower extremity blood pressures.

Meningococcemia and rash

- Caused by bacteria Neisseria meningitidis - onset = abrupt, accompanied by fever, chills, malaise, prostration. - initial rash may be urticarial, maculopapular, or petechial (marked by small, purplish, hemorrhagic spots). - fulminant cases: can become purpuric, marked by large hemorrhages into skin.

ITP cause

- Caused by binding of antiplatelet antibody to platelet surface, leading to removal and destruction of platelets in spleen and liver. - most common cause of isolated thrombocytopenia in otherwise healthy children.

Most common cause of diabetes associated death in children

- Cerebral edema Note: Bicarb drip can worsen this

Habit cough

- caused by habitual perpetuation of cough begun with a viral URI - Continued coughing irritates airway further, leading to a stronger stimulation to cough. - cough is typically very loud, short, dry, brassy and spasmodic. - unchanged by exercise or cold air and classically resolves during sleep.

CXR: RDS

- diffuse reticulogranular appearance of lung fields ("ground glass appearance") - air bronchograms.

Typical early childhood growth patterns

- double BW by 4-5 months - triple BW by 1 yr. D - double birth length by 4 years

Benign causes of proteinuria (2)

- Children excrete 1+ to 2+ (30-100 mg/dL) of protein during fever or after significant exertion. Will clear after resolution of fever or on cessation of exertion. - Orthostatic proteinuria: frequent finding in adolescents and does not signify renal disease. As much as 1500 mg/1.73 m2 may be excreted in 24-hour collection, but protein excretion occurs when patient is standing, not while recumbent. When first morning urine is checked it should be negative for protein.

Classic signs of CHF in newborn

- dyspnea with feedings - diaphoresis - poor growth - an active precordium - hepatomegaly

Solid Foods in setting of Vomiting and Diarrhea

- Children who have vomiting and diarrhea and are not dehydrated should continue to be fed age-appropriate diets. - Children who are dehydrated should be fed as soon as they have been rehydrated. - BF and formula feeding can continue through the period of rehydration. (especially important in lesser developed countries where malnutrition is an important contributing factor to morbidity and mortality associated with diarrhea and dehydration.)

caput succedaneum

- edematous swelling over the presenting portion of the scalp of an infant. - overlies periosteum - CROSSED suture lines. - DOES NOT cause hyperbilirubinemia (consists of serum)

Guidelines for Meningococcal Prophylaxis

- Close contacts , also recommended for those health care workers who had intimate exposure (such as occurs with unprotected mouth-to-mouth resuscitation, intubation, or suctioning before antibiotics are administered). Household, childcare, and nursery school contacts are considered high risk. - In adults: ciprofloxacin is drug of choice. - In children (< 18 years old): either oral rifampin or IM ceftriaxone may be used for prophylaxis. - Alternatives: Rifampin, ceftriaxone, and azithromycin are alternatives. - NOT RECOMMENDED FOR PREGNANT WOMEN: rifampin, ciprofloxacin

Rhonchi

- Coarse, low-pitched rattling sounds heard best in expiration. - due to secretions and narrowing of airways. - Seen in bronchitis

Wart tx

- 2/3 of warts spontaneously resolve within 2 years, so observation is always an option. However, it is easier to treat smaller warts early on than to wait until they expand. Aggressiveness of therapy for warts depends on the location, severity, and patient cooperation. - Salicylic acid: not very good data regarding treatment of warts, but OTC salicylic acid had best safety and efficacy in reviews of the literature. - Duct tape: Uncertain whether this works better than placebo (conflicting reports in the literature). Occlusion and irritation of skin is the theoretical mechanism. Immune system then cleans up area and wart. For a small or unobtrusive area, this option may be considered. - Liquid nitrogen: not been a lot of efficacy data for liquid nitrogen. Does not seem to be as effective as salicylic acid, though the treatment is a lot faster. Liquid nitrogen has been used for years and may be useful in older children and adults. May be too painful for younger children. - Cantharidin: Used to cause blistering at site of the wart. Applied only in a physician's office. Paucity of data documenting effectiveness. No longer FDA-approved for use as a single agent, but is still available in combination with other products. - Candidal antigen therapy: Considered immunotherapy. Very limited evidence for this therapy. According to recent review of the literature, - Surgically destructive methods of treating warts are sometimes used, but they may leave a significant wound or scar. Recurrence is common. All of these methods, with exception of duct tape, have also been used in treatment of molluscum contagiosum.

Focal segmental glomerulonephritis

- 2nd most common etiology of idiopathic nephrotic syndrome (~10% of patients) - Histio: most of glomeruli in FSGS appear normal or show mesangial proliferation, while others, especially juxtamedullar glomeruli, show segmental scarring in one or more lobules. - leads to involvement of ALL glomeruli, and to ESRF in most - only ~20% respond to steroid or CYCLOPHOSPHAMIDE therapy. - even with transplantation, disease may recur in transplanted kidney. - Genetic testing currently being developed to help distinguish familial forms of FSGS (which are unlikely to respond to immunosuppressive therapy) from sporadic cases (more likely to respond to immunosuppression).

Systemic-onset juvenile idiopathic arthritis (JIA)

- 3 groups: Oligoarthritis (or pauciarticular disease), Polyarthritis, or Systemic-onset disease (also called Still's disease) - Prolonged fever could suggest Still's disease - Rash - Arthritis (although active arthritis in Still's disease often presents months to years after onset) - Visceral involvement (e.g., hepatosplenomegaly, lymphadenitis, serositis)

When does infant botulism usually present?

- 3-4 months of infancy - poor suck and weak cry

Acute otitis media in kids onset, cause, sxs

- 3-5 days after onset of upper respiratory symptoms (common) - One of more specific symptoms is otalgia (ear pain, tugging at ears). - fever, irritability, cough, anorexia - less commonly" vomiting and diarrhea.

Typical Breastfeeding Pattern

- 8-12 times in 24 hours. - Feedings may last up to 60 minutes but gradually become shorter in duration, ~10-15 minutes at each breast. - Increasingly frequent or consistently lengthy feeding sessions may indicate a problem, especially if the infant is not gaining weight.

Prehypertension in kids

- 90-95th%ile systolic/diastolic bp - Therapeutic lifestyle changes should be implemented - f/u BP 6 months - Guidelines do not recommend a diagnostic work-up for a secondary cause of hypertension for children with blood pressure values in the prehypertension range unless there is a concern for a possible underlying cause in the patient's medical history, exam, or family history.

Milestones in speech development up to 2yrs

- < 7 days: Can distinguish mom voice -< 2 weeks of age: Can distinguish dad voice - 6-8 months : few consonant sounds to vowel sounds. May say "mama" or "dada" but does not attach them to individuals. - 1 year: Will attach "mama" or "dada" to correct person. Responds to one-step commands such as "Give it to me." - 15 months: Continues to string vowel and consonant sounds together (gibberish), but may imbed real words. May say as many as 10 different words. - 18 months: Can say nouns (ball, cup), names of special people, and a few action words or phrases. Can add gestures to speech, may follow a two-step command. - 2 years: Can combine words, forming simple sentences like "Daddy go."

Juvenile idiopathic arthritis epi, sxs, tx

- <16 years of age - arthritis in at least 1 joint for > 6 weeks. - can be associated with a rash Subtypes,: 1) Systemic (with constitutional sxs like fever and rash) 2) Oligoarthritis (previously called pauciarticular, typically affects knee; onset s acute,with asymptomatic iridocyclitis); 3) Polyarthritis (RF positive or negative) 4) Psoriatic arthritis 5) Enthesitis-related arthritis (has overlapping features with multiple categories or does not meet full criteria for one category). - Early referral to PT important: characterized by prolonged or spiking fever, rash, and arthritis. - Early tx and physical therapy can help prevent joint deformities and improve long-term functionality.

Most common organisms responsible for septic arthritis by age include:

- <2mos: Staph aureus GBS, E coli (neonates < 2 months) - older children: Staph aureus, Haemophilus influenzae, Strep pneumo - Adolescents: Neisseria gonorrhea

Pyuria

- > 5 WBCs per high-power field (hpf) in a centrifuged urine considered positive. - If a counting chamber is used, then > 10 WBCs per microliter in uncentrifuged urine is considered positive.

Mantoux test in children

- > 5 mm in high-risk children - > 10 mm in moderate-risk children - > 15 mm in low-risk children. - In symptomatic children, culture of M. tuberculosis organism should be obtained from a sputum sample, or from a first morning gastric aspirate in young children.

Lab abnormalities in DKA

- Decreased pH on a venous blood low because of the metabolic acidosis caused by the elevated ketoacids in the blood. - Decreased serum NA; results from osmotic movement of water into extracellular space in response to hyperglycemia and hyperosmolarity (dilutional hyponatremia), as well as from increased renal sodium losses. - Normal K: total body potassium will always be depleted through urinary losses, but pt's serum potassium level can be high, normal or low. K is usually added to the IVF after initial volume expansion and after urine output is established, unless there are EKG changes (peaked T waves). - DECREASED Bicarbonate, because of metabolic acidosis caused by elevated ketones and lactic acid in the blood. - ELEVATED: Creatinine: Even though renal fx may be normal, can be elevated due to severe dehydration (prerenal azotemia). - ELEVATED: Serum glucose - ELEVATED Serum ketones: Serum ketones, or a serum beta-hydroxybutyrate level, will be elevated. These will be followed closely to determine how the patient responds to insulin therapy. - ELEVATED Urine ketones: as serum ketones spill over into the urine. Should be monitored with every void until they clear.

Physiologic Jaundice

- Def: total bilirubin level ≤ 15 mg/dL (≤ 257 μmol/L) in full-term infants who are otherwise healthy and have no other demonstrable cause for elevated bilirubin. - Almost all newborn infants have hyperbilirubinemia, but is benign and self-limited. - usually first noticed on 2nd or 3rd day of life, with bilirubin level reaching its peak at day 3 or 4 of life. Causes: - Increased bilirubin production (from breakdown of short-lived fetal red cells) - Relative deficiency of hepatocyte proteins and UDPGT - Lack of intestinal flora to metabolize bile - High levels of β-glucuronidase in meconium - Minimal oral (enteral) intake in first 2-4 days of life, resulting in slow excretion of meconium (especially common with breastfed infants).

Diagnosis of Congenital Rubella

- Detection of rubella-specific IgM antibodies usually indicates recent postnatal infection or congenital infection. - Because false-positives can occur, diagnosis can also be confirmed by stable or increasing serum concentrations of rubella IgG over several months. - Dx is difficult after one year of age.

Crigler-Najjar syndrome

- Due to the absence or low levels of UDP glucuronosyltransferase 1 family, polypeptide A1. - Can cause severe (type I) or mild/moderate (type II) jaundice. - Also very rare.

What are you worried about during nephrotic syndrome?

- During a nephrotic syndrome relapse with steroid use, pts at high risk for infection. - high index of suspicion, prompt evaluation (including cultures of blood and peritoneal fluid), and early tx with broad spectrum antibiotics to cover G+ and G- organisms are critical to preventing life-threatening illness. - Increased risk due to following: a) Decreased Ig levels b) Edema fluid acting as culture medium c) Protein deficiency d) Decreased leukocyte bactericidal activity e) Immunosuppression from steroids d) Decreased splenic perfusion due to hypovolemia e)Urinary loss of complement factor (properdin factor B) that opsonizes certain bacteria.

Dx, prognosis and tx of slipped capital femoral epiphysis

- Dx: xray showing posterior displacement of femoral head (ice-cream scoop slipping off cone) - Prognosis: Depends on degree of slip and accompanying complications, particularly avascular necrosis of femoral head and destruction of articular cartilage. - Tx: Tpinning to stabilize the epiphysis but no manipulation.

Evaluation of congenital heart defect

- ECG: expected to be abnormal, demonstrating chamber enlargement. - CXR: information about heart size and prominence of pulmonary vasculature markings. - Echocardiography: more informative when combined with cardiology consultation. Use in primary pediatric care setting is controversial, and most pediatric cardiologists still agree that it is not appropriate as first-line testing

Dx PSGN

- Elevated antistreptolysin-O (ASO) titer - Positive streptozyme test - Elevated anti-DNAase B antibodies - Low C3

Antibiotic Treatment of Meningococcemia

- Empiric coverage for suspected meningococcemia is ceftriaxone. - If susceptabilities dictate, most appropriate antibiotic treatment for meningococcemia is often Penicillin G: - Pediatric dose: 250,000-300,000 units/kg/day (maximum 12 million units per day) divided every 4-6 hours - Adult dose: 12-24 million units daily divided every 4-6 hours

Asthma follow up intervals

- Every 2-6 weeks until asthma is stabilized - In 1- to 6-month intervals, depending on level of control and underlying severity.

Pre-diabetes dx

- FBG: 100-125mg/dL - GTT: 140-199 mg/dL 2 hrs following a glucose load - no formal recognition of "prediabetes" for those with intermediate HbA1c values BUT those with HbA1c levels 6.0 to < 6.5% are at very high risk of developing diabetes—(1x risk of the general population.

Cause of hepatomegaly in CHF

- Fairly consistent finding in children with congestive heart failure. - Decreased renal blood flow, via activation RAS, leads to fluid retention, systemic venous congestion, and hepatomegaly.

Occult bacteremia

- Febrile children ages 3-36 months without discernible focus of infection may have an "occult" bacteremia - usually caused by Streptococcus pneumoniae. - Other than fever, children with occult bacteremia often have no additional signs or symptoms of illness. - Undiagnosed, child with occult bacteremia is at risk for development of a more serious bacterial infection such as meningitis or osteomyelitis, through bacterial seeding of these distant sites.

Newborn discharge conditions

- Follow-up: Any infant discharged from nursery before 48 hours of life must be evaluated by a health care practitioner within 48 hours. - Feeding: Q2-4 hours, feeding 10-15 minutes on each side. - Jaundice: total bilirubin should be measured prior to discharge. If low level is identified, no further testing may be needed. -Vitamin D: recommends that exclusively BF infants receive a daily dose of 400 IU of vitamin D, because human milk does not provide adequate intake. This supplementation should continue until infant is weaned to either cow's milk or a formula containing vitamin D. Standard formulas all contain at least 400 IU of vitamin D in a day's supply. - Car seat - Sleep position and co-sleeping

Factors that increase the risk of maternal HIV transmission to child

- Frequent, unprotected sex during pregnancy (chorioamnionitis + other sexually transmitted infections increase the risk of HIV transmission.) - Advanced maternal HIV disease -> high viral load - Membrane rupture >4 hrs prior to delivery if mother is not on antiretroviral therapy - Vaginal delivery - Breastfeeding - Premature delivery <37 weeks

What dx does a rectal exam help with? (4)

- GI bleeding - Intussusception - Rectal abscess - Impaction

Signs of Respiratory Distress

- Grunting - Tachypnea - Retractions: end of expiration, audible sound of air being expelled through partially closed glottis as the infant attempts to increase transpulmonary pressures, increase lung volumes, and improve gas exchange.

Physiologic effects of anticholinergic drug ingestion

- HR elevated - Hyperthermia - Dry - Dilated pupils - Hypoactive abd

Cushing's triad

- HTN - Bradycardia - irregular resp

Signs of cerebral edema

- HTN - Decreased oxygen sat - Restlessness, irritability - drowsiness (lethargy) - Cranial nerve palsies: CN VI - Abducens nerve - Abnormal pupillary responses: unequal pupils, fixed dilated pupils, absent response unilaterally or bilaterally - Bradycardia - Severe vomiting - Headache

VSD murmur characteristics and timing

- Holosystolic starting with S1 - blowing - Heard best at the LLSB - Can be associated with hyperactive precordium - Only heard till later: Newborns have elevated pulmonary vascular resistance. When the systemic and pulmonary vascular resistances (PVR) are nearly equal, there is no reason for blood to shunt through the VSD. The murmur of a VSD will not appear until the PVR drops, usually at a few days to weeks of age. This is why, typically, VSD murmurs are not heard in the nursery.

Common sources of lead exposure

- House paint used before 1978 -esp before 1960. - Deteriorating paint produces lead-containing dust, particularly during renovation. - Soil - Plumbing, pipes - Hobbies, occupational exposures - Imported toys, ceramics, candy, cosmetics - Folk remedies

Erythema nodosum

- Hypersensitivity reaction presenting as red, tender, nodular lesions on pretibial surface of the legs. - Many possible etiologies, a few of which include infections, drugs, and IBD - Primary lesions are nodules, not pustules.

Differential dx of abd pain and bloody stools (6)

- IBD - Celiac - Bacterial gastroenteritis - Giardiasis - PUD - HSP

Intrapartum Antimicrobial Prophylaxis for gbs

- If one of the following is present and mother is in labor WITH ruptured membranes: 1) Gestation of < 37 weeks 2) Membranes ruptured ≥ 18 hours 3) Temperature of ≥ 38°C (100.4°F) 4) Intrapartum nucleic acid amplification test (NAAT) is positive for GBS 5) Previous infant with invasive GBS disease 6) GBS bacteriuria during any trimester of current pregnancy 7) + GBS vaginal-rectal screening culture in late gestation during current pregnancy 8) Unknown GBS status at onset of labor and any of the following: - Delivery at < 37 weeks' gestation - Amniotic membrane rupture ≥ 18 hours - Intrapartum temperature ≥ 38°C (100.4°F)

KUB screens for... (5)

- Ileus (sometimes with air-fluid levels) - Fecaliths (seen with appendicitis) - Free air (with perforated viscus) - Malrotation of the intestines - Gall stones.

Weight gain in the newborn

- Immediately after birth, most newborn infants lose some weight, but uncommonly exceeds 10% of birth weight. - Healthy infants born at full term gain ~20-30g/day during first 4 months of life. - Weight doubles by ~4 months for the average infant, although some infants reach this weight by 3 months. - Half of the weight gained during the first 4 months of life is in the form of fat, making the 4-month-old infant the fattest healthy human, with about 25-26% of weight as fat. Formula-fed infants tend to gain weight faster than do breastfed infants because they ingest more calories.

Growth in sickle cell disease

- Impairment of growth is common in children with SCD. This is probably multifactorial and may be due to any one or combination of the following: a) Chronic anemia b) Poor nutrition c)Painful crises d) Endocrine dysfunction e) Poor pulmonary function

Hypoglycemia cut off in Neonate and tx guidelines

- Important to screen all newborns at risk for glucose instability - target glucose screen value prior to routine feeds is > 45 mg/dL. - If infant is symptomatic from hypoglycemia and glucose is <40 mg/dL, IV glucose should be administered. - If, during first 4 hrs of life, infant shows no signs of hypoglycemia but initial screen and post-prandial glucose are <25 mg/dL, administration of IV glucose is recommended. - Between 4 and 24 hours of life, threshold for administration of IV glucose to an asymptomatic infant increases to 35 mg/dL.

Risk of Epilepsy in a child with febrile seizures

- In a child who has a febrile seizure, risk of developing epilepsy is slightly increased above 0.5-1% baseline population risk. - epilepsy more common among those children with early, recurrent febrile seizures, especially if there is a FMH of epilepsy. - Children with complex febrile seizures + those with abnormal developmen = increased risk of epilepsy.

What is chronic OME associated with?

- Increased risk for permanent sensorineural hearing loss (SNHL) - Tympanosclerosis - Adhesive otitis media - Cholesteatoma

Activated charcoal

- Indications: for ingestions not due to small molecules or heavy metals. - CI in patient with a loss of protective airway reflexes due to risk of aspiration; selective intubation should be considered in such cases. Additional doses of activated charcoal may be indicated due to decreased gastrointestinal motility as a result of the anticholinergic effects of tricyclics. A single dose of a cathartic agent may be given with the initial dose of charcoal.

Why give penicillin to a child with SCD?

- Infants and young children with SCD are at greatly increased risk for sepsis. - Penicillin decreases mortality - continue until 5-6 years of age - decreased splenic function leads to decreased resistance to infection with encapsulated organisms (S. pneumoniae, Haemophilus influenzae type b, N. meningitidis).

B. pertussis complications

- Infants tend to have more complications - difficulty feeding because of their cough - CNS complications such as apnea.

Treating SGA Infants born to moms with +HBsag to Prevent Vertical Transmission of Hepatitis B

- Infants weighing <2000 grams - hep B vaccine - hepatitis B immune globulin (HBIG) within 12 hours of delivery. - ALSO give routine series of three doses of the vaccine beginning at age 1 month for a total of 4 doses. - Vertical transmission can be prevented in 85-95% of cases using these interventions. - At 9-18 months: test for anti-HBs (antibody to Hepatitis B surface antigen) and HBsAg, and—if found to have inadequate antibody protection—should be re-immunized.

G6PD deficiency and jaundice

- Infants with G6PD deficiency may also be jaundiced without anemia. - Cause: decreased bilirubin conjugation - result of a gene interaction between G6PD deficiency and variant promoter for gene for bilirubin-conjugating enzyme, UDP glucuronosyltransferase (similar to what is seen with Gilbert's syndrome where there is a partial deficiency of this bilirubin conjugating enzyme)

Evaluation of incomplete Kawasaki disease

- Infants ≤ 6 months old on day ≥ 7 of fever without other explanation should undergo laboratory testing - if evidence of systemic inflammation found, do echocardiogram, even if infants have no clinical criteria. Can treat before echo - characteristics suggesting disease other than Kawasaki disease include exudative conjunctivitis, exudative pharyngitis, discrete intraoral lesions, bullous or vesicular rash, or generalized adenopathy. - Supplemental lab criteria: a) albumin ≤ 3.0 g/dL b) anemia for age c) elevation of ALT d) platelets after 7 days ≥ 450 000/mm3 e) WBC ≥ 15 000/mm3 f) urine ≥ 10 white blood cells/high-power field. - If echocardiogram is positive, tx should be given to children within 10 days of fever onset and those beyond day 10 with clinical and laboratory signs (CRP, ESR) of ongoing inflammation. - Typically peeling begins under the nail bed of the fingers and then toes.

Differential Dx of lethargy in 2 week old infant

- Infection (sepsis, meningitis) - Intracranial pathology (hemorrhage from trauma, hydrocephalus, hydranencephaly) - metabolic disorder - chromosomal anomaly

5 Non infectious causes of generalized lymphadenopathy

- Lymphomas - Leukemia - Histiocytosis - Metastatic neuroblastoma - Rhabdomyosarcoma

Risks for cerebral palsy

- Major CP-associated pathologies other than acute intrapartum hypoxia were identified in 98 % of cases. - Some children had more than 1 associated pathology. - Risk of each of above pathologies is as follows: a) Prematurity 78% b) IUGR 34% c) Chorioamnionitis 28% d) Perinatal asphyxia* 10%

Why is interpreting ECGs in infants and children complicated?

- Normal voltage is very age-dependent. - Newborns and young infants normally have more right ventricular voltage, more rightward axis, than older infants and adults --> fetal circulation, lungs are not contributing to ventilation and resultant pulmonary vascular resistance is elevated --> thickening of RV, with resultant elevated right ventricular voltages and a rightward axis in newborns, which is normal. - As infant gets older and pulmonary vascular resistance normalizes,i right ventricle thins and ECG voltages decrease.

Tx mild acne

- OTC benzoyl peroxide (BPO) - Retinoids (e.g., tretinoin [Retin-A] or adapalene [Differin]) work by normalizing follicular keratinization and are considered drugs of choice for comedonal acne.

Giving Difficult News

- Make sure patient and/or family are as comfortable as possible and that any support people (family or close friends) are present. - Do not make assumptions about patient's or family's preferences. - ask specifically what the patient/parent(s) know and what they are most concerned about in order to give them information they are ready to hear; then you can tell them about the diagnosis or condition of the patient, interpret the seriousness (without euphemisms), explicitly describe how you are treating the condition, let them know how the patient is doing, and give the prognosis. - Gauge patient's or family's understanding of situation. - Speak in basic terms and do not use medical terms that can confuse non-medical personnel. - While it is important to be honest and direct, be careful not to overwhelm with information. - Always find some way to offer hope. If things are bleak, focus the patient/parent on short-term goals like what to hope for in the next 30 minutes. Also, by giving them a task (even one as simple as holding the patient's hand or calling family members, etc.) the family feels involved in the care.

5 Infectious Causes of Generalized Lymphadenopathy

- Measles: marked generalized lymphadenopathy and splenomegaly that may last several week - Infectious mononucleosis: EBV, CMV, HIV - Histoplasmosis - Toxoplasmosis - Mycobacteria (can also present as localized lymphadenopathy)

TSH follow up in patient with congenital hypothyroidism

- Measure TSH and free T4 at 2 and 4 weeks after initiating therapy, then: - every 1-2 months until 1 year of age, - every 2-3 months until 3 years of age - 3-12 t months until growth is completed.

Primary HTN in kids tx

- Medications (typically reserved for children with Stage 2 HTN, children with secondary hypertension, and children with evidence of target-organ effects) - Dietary changes (diets lower in sweets and added sugars, fats, and red meats have been associated with lower blood pressures; lower dietary sodium has also been associated with reduced blood pressure) - Weight loss (if overweight) - Physical activity

Fussiness in a young child differential

- Meningeal irritation - HA from intracranial irritation - Simple exhaustion

Small fontanel size associations

- Microcephaly - Craniosynostosis - Hyperthyroidism - A normal variant

Steroid potencies

- Mild: Class 6 & 7 hydrocortisone acetate, 1% (OTC) - Intermediate: Class 4 & 5, triamcinolone acetonide, 0.1% - Potent: Class 2 & 3 betamethasonedipropionate, 0.05% - Super Potent: Class 1 clobetasol propionate, 0.05% (HTBC)

Acne severity

- Mild: Comedonal acne with a few papules or pustules mixed in - Mod: significant inflammatory lesions with concern for scarring - Severe: Nodulo-cystic type, with an even higher risk for significant scarring

Cholinergic drug ingestion symptoms

- Miosis and blurred vision - Increased gastric motility (nausea, vomiting, diarrhea) - Excessive tearing, salivation, sweating and urination - Bronchorrhea and bronchospasm - Muscle twitching and weakness - Bradycardia - Seizures and coma Mnemonic: "SLUDGE" (salivation, lacrimation, urination, defecation, GI motility, emesis)

CT scan for abdominal pain

- More sensitive and specific than a KUB, but also more expensive and difficult to obtain in children. - concern: amount of radiation children receive from CT scans. - CT : excellent way to look for abscesse, has been studied as a way to dx appendicitis (sensitivity of CT scan for diagnosing appendicitis in children is 94-97%; the specificity, 87-99%).

Irritant dermatitis

- Most common cause of diaper rash. - Due to prolonged exposure to moisture, friction, digestive enzymes (worse w/ diarrhea). - Presents as irregular areas of erythema with skin maceration on convex surfaces of the skin Typically spares the intertriginous creases. Tx: zinc oxide-containing creams or ointments. The barrier provided by the zinc oxide helps limit contact of urine and feces with skin allows the rash underneath to heal.

Slipped capital femoral epiphysis epidemiology, etiology and presentation

- Most common hip disorder in adolescents - posterior displacement of capital femoral epiphysis from femoral neck through cartilage growth plate. - limp and IMPAIRED INTERNAL ROTATION - Get: months of vague hip or knee symptoms and limp with or without an acute exacerbation. - more commonly in obese adolescents, suggesting that mechanical strain on growth plate could be at least partially responsible for the slip. - Endocrine factors also may be important.

strep rash

- Most commonly associated with rash of scarlet fever - fine, erythematous, sandpaper-like rash accentuated at skin creases. - known to cause an urticarial rash.

Pneumonia in an infant

- Most have cough, tachypnea, fever, rales, or low SaO2. - Unusual (but not impossible) for a child with pneumonia to have no symptoms referable to respiratory system. - In an immunized child with no respiratory findings, a chest x-ray is not required. - EXCEPTION: if the child's WBC is > 20,000 cells X 103/μL. (Interestingly, however, if child looks well, a WBC is not recommended.)

RF for Idiopathic intracranial HTN (4 categories)

- Obesity - Meds: Vit A, tetracycline, OCP, steroid - Metabolic disorders:galactosemia, hypoparathyroidism - Infections: sinusitis, chronic otitis media

Causes of jaundice in the newborn

- Physiologic - BF - Hemolysis a) Antibody-positive hemolysis: Rh incompatibility, ABO incompatibility, Incompatibilities with minor blood group antigens (much less common) b)Antibody-negative hemolysis: infants who have RBC membrane defects (e.g., spherocytosis) or RBC enzyme defects (G6PD or pyruvate kinase deficiency). - Non-hemolytic red cell breakdown : Extensive bruising from birth trauma, Large cephalohematoma or other hemorrhage (e.g., intracranial), Polycythemia, Swallowed blood (large amounts) during delivery - Metabolic errors: a) Crigler-Najjar syndrome: from decreased bilirubin clearance caused by deficient or completely absent UDPGT. b) Galactosemia and hypothyroidism - Ethnicity: Asian - Prematurity - Bowel obstruction - Birth at high altitude

HA and sinusitis

- Poorly controlled allergic rhinitis can trigger exacerbations of acute and chronic sinusitis - common causes of headaches in children.

Minor RF for hyperbilirubinemia

- Pre-discharge TSB or TcB level in the high intermediate-risk zone - Gestational age 37-38 week - Jaundice observed before discharge - Previous sibling with jaundice - Macrosomic infant of a diabetic mother -Maternal age >25 y - Male gender

Major RF for hyperbilirubinemia

- Pre-discharge total serum bilirubin (TSB) or total conjugated bilirubin (TcB) level in high-risk zone - Jaundice observed in first 24 hours of life - Blood group incompatibility, with positive direct antiglobulin test - Gestational age 35-36 week - Previous sibling received phototherapy - Cephalohematoma or significant bruising - Exclusive BF, particularly if nursing is not going well and weight loss is excessive - East Asian race

When to hospitalize patient with PID

- Pregnancy - Previous noncompliance - High fever - Intractable vomiting - Inability to exclude a surgical emergency

Measles rash

- Prodrome of fever: over 38.3 C, or 101 F) - Then: cough, coryza, and conjunctivitis, - Maculopapular rash starts on NECK, behind ears, and along hairline. - spreads downward, reaching feet in 2-3 days - initial rash appears on buccal mucosa as red lesions with bluish white spots in center (known as Koplik spots).

Pulmonic stenosis

- Prominent systolic ejection click just after S1 - Harsh systolic ejection murmur

Hidradenitis suppurativa

- Pustular lesions caused by occlusion of APOCRINE follicular units (instead of pilosebaceous units). - superinfected with Staphylococcus aureus or Streptococcus pyogenes.

Work up of pyloric stenosis

- Pyloric ultrasound: study of choice - Upper GI contrast study: If ultrasound is unavailable, will demonstrate a very narrow pyloric channel ("string sign"), indentation of hypertrophied pylorus on antrum of stomach, and delayed gastric emptying. - If concern for malrotation or volvulus: upper GI study should include imaging of contrast passing through small intestine as well. But absence of bilious emesis suggests no obstruction beyond pylorus. - Lab: hypochloremia, hypokalemia, and alkalosis.

Retinopathy of prematurity (ROP)

- RF: premature infants, particularly those weighing < 1500 g -~ 50% of infants weighing <1200 g develop ROP. - extraretinal fibrovascular proliferation - severe cases: may cause retinal detachment and blindness. - Development in children with ROP may be delayed depending on degree of visual impairment.

PID RF and causes

- RF: sexually active females 15-19 years are because of both biological and behavioral factors: fewer protective abs in vagina, cervical ectropion which represents transitional zone between columnar and squamous epithelium is not fully matured; cells in this zone are particularly susceptible to STDs, cervix is therefore easier to infect. Behavioral factors include intercourse during menses, infrequent or no condom use, multiple sexual partners. - Causes: > 50% of cases: Neisseria gonorrhea or Chlamydia trachomatis - Lower-tract infection w/ pathogens leads to alteration of normal vaginal flora and allows bacteria such as E. coli, Bacteroides species, other anaerobes, Mycoplasma hominis or Ureaplasma urealyticum access to uterus and fallopian tubes.

Fitz-Hugh-Curtis syndrome

- RUQ pain in association with PID - N. gonorrhoeae or Chlamydia trachomatis. - Infectious material may spill from uterus and track alongq paracolic gutter and cause inflammation of hepatic capsule and diaphragm. - Get RUQ pain and referred scapular pain.

Cardiogenic shock, def, signs and sxs

- Rare in children, but may be associated with: a) Severe congenital heart disease b) Dysrhythmias c) Cardiomyopathy d) Tamponade Signs and symptoms: - Cool extremities - Delayed capillary refill (> 2 seconds) - Hypotension - Tachypnea - Increasing obtundation - Oliguria

GERD in infant

- Regurgitation/spitting up may be difficult to distinguish from true vomiting. - Infants who reflux with overfeeding may sometimes have forceful vomiting. - Severe esophagitis may result in blood-streaked emesis. - Pain from reflux or esophagitis may lead to feeding aversion when GERD is severe. - infant who is dehydrated due to severe GE reflux should also have significant failure to thrive.

At birth circulation changes

- Removal of low-resistance placental circulation by cutting umbilical cord. - Initiation of air breathing by newborn infant. - Reduction of pulmonary arterial resistance. - Closure of PFO and PDA.

Timing of retinoid meds

- Retinoids need to be used at NIGHT, because they can cause photosensitization and lead to a significant sunburn. - Tretinoin is also inactivated by oxidation of BPO (so BPO cream should be applied in morning). - Tretinoin also must be applied to bone-dry skin or it may be significantly irritating. - It is important to make sure teens know that retinoids can make acne transiently look worse.

Rocky Mountain spotted fever (RMSF)

- Rickettsia rickettsia - Fever - Headache - Rash (typically starts on ankles and wrists and progresses centrally and to palms and soles*; may be maculopapular at first, quickly becoming petechial; in 5% of cases, there may be no rash) - Myalgias

Peak expiratory flow asthma monitoring can be used for

- Short-term monitoring - Managing exacerbations at home and in ED - In daily long-term monitoring of asthma—particularly in moderate to severe asthma

Treating SGA Infants born to moms with unknown HBsag status to Prevent Vertical Transmission of Hepatitis B

- Should receive hepatitis B vaccine within 12 hours of delivery. - Administration of HBIG can be delayed until maternal HBsAg is known, and is effective if given within 7 days following delivery if the patient is greater than 2 kg at birth.

Simple v complex febrile seizure

- Simple: more common, <15mins, once in a 24 hr period, generalized - Complex: less common, >15 minutes, more than once in a 24 hr period, focal.

Large fontanel size associations

- Skeletal disorders:rickets, osteogenesis imperfecta - Chromosomal abnormalities: Down syndrome - Hypothyroidism - Malnutrition - Increased ICP

TB RF

- Spending time with individual known or suspected to have TB disease - immunosuppressed - sxs of tb - Living in (or coming from) a country where TB disease is very common (most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia) - Living somewhere in the U.S. where TB disease is more common (e.g., a homeless shelter, migrant farm camp, prison or jail, and some nursing homes) - Use of injected illegal drugs. If an individual has any of the above risk factors, a PPD should be placed and read by a medical professional in 48-72 hours.

Physical exam in kid with SCD (3 things)

- Spleen - Sclera for icterus - Neuro exam for stroke

Differential dx for pustular rash

- Staph follicullitis: below waist or in groin area - Acne vulgaris:neck face chest upper back, upper arms - Hidradenitis suppurativa: axilla, groin, inframammary regions, perineal and perianal regions in men. - Rosacea: malar and nasal folds - Perioral dermatitis (variant of rosacea): around mouth, nose, eyes

Most common bacterial causes of septic arthritis (5)

- Staphylococcus aureus - Streptococcus (neonate: group B/infant and older child: Group A & S pneumoniae) - H. influenzae type b (in unimmunized children) - Neisseria gonorrhea (adolescents) - Kingella kingae (in children <4 years)

Scarlet fever

- Starts as a finely punctate pink-scarlet exanthem. - appears on upper trunk 12-48 hours after onset of fever. - exanthem spreads to extremities -> become confluent -> feels like sandpaper. - Rash fades in 4-5 days and is followed by desquamation of skin. - Pastia's sign: Linear petechiae are evident in body folds. - pharynx: beefy red and tongue is initially white and rough (strawberry tongue); within 4-5 days white coating sloughs off and tongue becomes bright red.

Diaper candidiasis

- Starts off as erythematous papules that become confluent, bright red plaques. The inflamed plaques are surrounded by more erythematous papules called "SATELLITE" lesions. - Treatment: anti-fungal medication nystatin is effective against candida and is probably most often used as it is approved for all ages by FDA. Imidazole antifungals such as miconazole and ketoconzole can also be effective, but some of these products are not approved for use in infants.

Lethargy medical definition

- State of deep and prolonged unconsciousness, resembling profound slumber, from which person can be aroused but into which he/she immediately relapses. - Can be a sign of poor perfusion of brain. - Often when parents say "lethargic" they mean "sleepy."

Steroid resistant patient with proteinuria

- Steroid-resistant pts: do not respond after 8 weeks Do renal biopsy to: - <6 months of age: increased chance of congenital nephrotic syndrome - Infants 3-18 months of age with hematuria - Children > 10 yrs if dx is not a drug reaction or postinfectious glomerulonephritis; - Children with T1DM < 10 years duration; - Children of all ages who have hematuria and proteinuria if mother has hematuria (Alport syndrome) - Children with HSP - Children with non-postinfectious glomerulonephritis with progressive decline in renal fx and OU; - Pts with suspected lupus nephritis with positive ANA, elevated anti-DS DNA titer, and a decrease in C3 that persists >3 months; - Patients with low serum complement at time of initial presentation not related to acute postinfectious glomerulonephritis; - Pts with SLE with proteinuria or nephrotic syndrome - Evidence of chronic renal insufficiency w/ persistent elevation of serum urea nitrogen and creatinine.

Transcranial Doppler (TCD) Studies in SCD

- Stroke occurs in ~ 10% of children with SCD - Evaluation of cerebral blood-vessel flow by - TCD has been shown to be useful screening tool for predicting risk of patients for stroke. - can help in evaluating which patients might benefit from prophylactic transfusion of RBCs. TCD studies are now recommended in children 2-15 years of age to determine their risk for stroke.

Symmetric vs asymmetric IUGR

- Symmetric IUGR refers to a growth pattern in which head, length, and weight are decreased proportionately. - Asymmetric IUGR refers to a greater decrease in the size of the length and/or weight without affecting head circumference ("head-sparing phenomenon").

Cerebral edema in DKA

- Symptomatic cerebral edema is a relatively rare (0.5-1% of pediatric DKA episodes) - associated with high rates of mortality (21-24%) and morbidity. - can occur at any point, even before treatment is initiated and up to 24 hours after initiation of treatment. - Cause: pathophysiology of cerebral edema is poorly understood, but epidemiologic research has identified several risk factors: a) High BUN concentration at presentation b) Profound acidosis with hypocapnia c) Attenuated rise in measured serum sodium with treatment d) Administration of bicarbonate.

Viral meningitis

- Symptoms typically less severe than with bacterial meningitis. - Commonly caused by enterovirus. - Fever. - May be other symptoms such as loose stools, rashes, or upper respiratory symptoms.

Problem with central access line in children

- Technique actually has more risks involved than IO access - Takes too long in infants and young children - high morbidity in infants - BUT in an older child or adult, however, a central line is acceptable if it can be placed within 90 seconds.

Babinski reflex

- Test L5 and S1 by gently stroking lateral aspect of sole from heel to ball, curving medially across ball. - Get: dorsiflexion of the big toe, often accompanied by fanning of the other toes - Nl to have in infants - may persist until 2 years of age in some children, but usually is absent by the time the child is walking. - Abnormal: persistence beyond 2 years

Red Reflex Examination in Neonates

- The best method for evaluating the red reflex is to turn off the room lights and stand at least a foot away from the child's face with the illuminated ophthalmoscope; this allows the examiner to look for both red reflexes simultaneously. - Infants with more darkly pigmented skin will have a light golden colored or silver-tinged "red reflex." - An absent red reflex (no reflection noted) may be caused by: a) A cataract b) An opacified cornea (such as in mucopolysaccharidosis) c) Inflammation of the anterior chamber d) Developmental anomalies of the eye Retinoblastoma, a potentially lethal malignancy (careful examination of the eye of an infant with retinoblastoma often identifies a white, irregular mass within the globe).

TORCH infections

- Toxoplasmosis - Other transplacental infections (by HIV, hepatitis B, human parvovirus, and syphilis). - Rubella -Cytomegalovirus Herpes virus type

Complications following tympanostomy tube placement:

- Tube otorrhea - Tympanosclerosis - Nonfunctional tube due to blockage - Residual perforation after extrusion of tympanostomy tubes.

Risk factors for T2DM in child

- Type 2 DM accounts for up to half of all new cases of diabetes in certain pediatric populations. - In the past 20 years, rates have increased as much as ten-fold in the pediatric population. - Obesity: ore strongly associated with obesity than with any other clinical condition. Most studies have found that mean body mass index (BMI) among children with type 2 DM is >95th reference percentile for age. - Ethnicity: Native American, African American, Latino, Asian American, Pacific Islander populations. - Age: Peak age at diagnosis in youth is between 12 and 16 years (midpuberty) -Sex (female; 3:1) - Sedentary lifestyle

LN of bacterial cervical adenitis

- Typically seen in children ages 1-5 years with history of recent URI -S. aureus and S. pyogenes most common -may have high fevers and a toxic appearance. -commmon: Overlying cellulitis and development of fluctuance.

Dx of septic arthritis of the hip

- US: useful for identifying effusion and for guiding a needle aspiration, or arthrocentesis. - - Arthrocentesis: difficult procedure best performed by an experienced orthopedic surgeon. Characteristics of Synovial Fluid 1) Turbid 2) Increased WBC, polymorphs 3) Low glucose 4) Gram stain of fluid should show bacteria on gram stain and a sample needs to be sent for culture.

Risk of UTI in an infant

- Uncircumcised male < 6 months (some say all males under 6 months and uncircumcised males under 12 months) - Any female under 24 months - Signs or symptoms pointing toward a UTI (e.g., suprapubic tenderness, history of UTI, foul-smelling urine) - Temp > 39 C (102.2 F), or fever ≥ 24 hours without a sources

Common features of down syndrome (8)

- Upslanting palpebral fissures - Small ears (usually less than 34 mm at maximum dimension in a term infant) - Flattened midface - Epicanthal folds - Redundant skin on back of neck (nuchal skin) - Hypotonia (most consistent finding in infants with Down syndrome) - Umbilical hernia - Space between 1 and 2 toe

RF to venous thrombosis in nephrotic syndrome (4)

- Urinary loss of proteins that inhibit coagulation (antithrombin III) - Destabilization of plts by hyperlipidemia - Increased fibrinogen levels and fibrinolysis - Increased blood viscosity due to rise in hct (especially if diuretics are used w/o albumin replacement).

Enterovirus rash

- Usually erythematous, maculopapular (can be petechial.) - may involve palms and soles. - In hand-foot-and-mouth disease (caused by Coxsackie virus): presents as vesicular rash on hands and feet and with ulcers in mouth. - Usually seen in late summer and early fall. - While fever associated with enteroviruses may be high, it usually lasts only a few days.

Septic shock

- When infectious organisms release toxins that affect fluid distribution and cardiac output. - typically require repeated boluses of fluid. - meds: epinephrine, norepinephrine or dopamine to enhance cardiac contractility and to vasoconstrict the vessels. - Patients in septic shock may present initially as compensated or "warm" shock, with: a) Warm extremities b) Bounding pulses c) Tachycardia d) Tachypnea e) Adequate urination f) Mild metabolic acidosis

Normal breastfeeding time

- Young infants who are breastfeeding usually nurse for 10-30 minutes a time, as often as every 1-2 hours. - Bottle-fed infants will often take more per feed and thus feed a little less often.

Meningococcal sepsis is suspicious when...

- a patient presents with fever and petechiae, even if looks overall well. - blood culture must always be done - antibiotics must always be given until disease can be definitely ruled out.

Biliary atresia timeline

- after 2 weeks of age with progressive jaundice and acholic stools. - Causes a DIRECT hyperbilirubinemia.

Difference between DTap and TdaP

- amount of diphtheria toxoid contained in each dose. - Pediatric DTaP (big D) contains 3-5 times more diphtheria toxoid than the adult Tdap (little d) and is only given to children 6 years old and younger. - Tdap is used for adults and children 7 years of age and older who need booster doses of diphtheria, tetanus toxoid, and acellular pertussis.

Langerhans cell histiocytosis

- another possible cause of diaper rash. - lesions tend to be crusty and weepy and may bleed. - If there is no change or progression of a diaper rash with treatment, then child should be referred to a dermatologist. - DX: is made by skin biopsy.

What Drugs Can Be Administered by IO?

- any drug that can be given intravenously can be administered safely via the IO route. - onset of action and drug concentration is comparable between both routes.

Physiologic jaundice timeline

- appears earlier than on day 4.

Atypical pneumonia cough

- atypical or viral pneumonia may present with symptoms consistent with URI - cough is same during day and night - cough exacerbated by exercise or cold air. - Cough may persist for 8-12 weeks. - Most common causative organisms: influenza, adenovirus, and mycoplasma; other organisms to consider include pertussis, HIV, and fungal. - Children receive vaccination against pertussis starting at 2 months of age, but immunity wanes during the teenage years if a booster is not given.

Bronchiolitis cause, sxs, cxr, and tx

- bronchiolar obstruction due to edema, mucus, and cellular debris - most common cause: RSV, other viruses such as influenza and parainfluenza may cause bronchiolitis as well. - wide spectrum of disease: most get mild URI sxs and a fever of 38.5-39 C; can progress to cough, wheezing, dyspnea and irritability. - CXR: hyperinflation, increased interstitial markings, peribronchial cuffing, and scattered atelectasis from bronchial obstruction. - Tx: supportive, aimed at maintaining adequate oxygenation and hydration. Antibiotics may be indicated if there is evidence of secondary bacterial pneumonia.

Tinea versicolor

- called "tinea," - actually an infection with yeast form of a fungus (Malassezia globosa as well as other malassezia species) that is part of normal skin flora. - Rash: pink, brown, or white lesions depending on background color of skin, and it has a fine scale; can change color. - Can be contagious; some people appear more susceptible to it than others. - Excess heat and humidity predispose to the infection. - Tx: selenium sulfide lotion. Recurrences are common, and pigment changes in the skin may take months to return to normal.

"Bag" Urine

- can be used in certain instances for child who has not been toilet-trained and cannot void on demand. - plastic collection bag with adhesive flaps adjacent to bag opening applied to perineum. - use for screening - high rate of contamination-> should never be used for culture.

LN of mycobacterial infection

- can cause diffuse LN or isolated lymphadenitis. - overlying skin may be erythematous initially - if left untreated -> violaceous as nodes enlarge. - Nodes may rupture through skin, resulting in draining sinus tract. - tx is surgical excision (no I&D as can also result in a sinus tract)

Complex partial seizure

- can occur at any age - last 30 secs-2mins - ***Alteration of consciousness(confusion, HA, sleep) in post ictal phase - tend to localize around 1)eyes (glassy-eyed) 2) mouth (lip-smacking, drooling, gurgling) 3) abdomen (nausea and vomiting). - Automatisms (quasi-purposeful motor or verbal behaviors that are repeated inappropriately) - 2ary generalization can occur in up to 1/3 of children, so important to question witnesses about initial features to help differentiate a complex partial seizure from a generalized seizure

Galactosemia

- cause of direct hyperbilirubinemia. If not detected early it also causes vomiting and can lead to death.

Infant colic

- cause: unknown. - crying typically starts after 2 wks of age, peaks at 6 wks, gradually lessens by age 3 or 4 months. - infant eats normally and has normal growth. - crying can create feelings of rejection, frustration, and anxiety in caregivers.

DKA pathophys

- caused by a relative or absolute deficiency of insulin (facilitates entry of glucose into peripheral tissues, and inhibits lipolysis, glycogenolysis, and tissue catabolism) - lack of insulin and excess counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone) --> catabolic state characterized by increased gluconeogenesis, lipolysis, glycogenolysis, and inhibition of glycolysis, which result in hyperglycemia and ketogenesis. - increased lipolysis -> increased mobilization of FFAs -> converted into ketones (acetoacetic and beta-hydroxybutyric acids). - increased production of ketones lowers blood pH -> metabolic acidosis, which is worsened by lactic acidosis from dehydration and poor tissue perfusion. - When circulating blood glucose levels reach ~180 mg/dL, an osmotic diuresis occurs, leading to hypovolemia, dehydration, and a loss of sodium, potassium, and phosphate in the urine. Intravascular volume depletion stimulates catecholamine release, which causes further lipolysis. The osmotic diuresis and hyperglycemia cause serum hyperosmolarity. Dehydration can result in renal impairment, which will exacerbate hyperglycemia

Hydroxyurea

- chemotherapeutic agent - shown to decrease severity and frequency of sickling disorders when administered daily to patients with more severe disease. - inhibits ribonucleotide reductase - increases fetal hemoglobin (HgF) - Improved nitric oxide metabolism - Reduced RBC endothelial interaction - Decreased erythrocyte density. overall: reduces hospitalization and increases total HbF in children with severe HbS S/e: hematologic and renal toxicity.

Diphteria

- child with pharyngitis and a low-grade fever, particularly if stridor or hoarseness is present. - dx is made when characteristic gray pseudomembrane is seen in the pharynx. - index of suspicion should be raised if the child is not immunized.

Tx of hypoglycemia in newborn

- choice of intervention depends on presence or absence of sxs and any additional pbs such as tachypnea. - BF or bottle feeding of pumped breast milk or formula depends on ability of infant to take feedings orally. Tachypnea may prevent adequate intake of glucose via oral feeds. In this situation, placement of a nasogastric tube and administration of either breast milk or formula would be appropriate, with resumption of breast or bottle-feeding as soon as rr allows. - If baby is symptomatic from hypoglycemia, iv infusion of dextrose should be started immediately as it guarantees a stable source of glucose - Glucose water does raise the serum glucose level, but only transiently. Rebound hypoglycemia often develops 1-2 hours after feeding glucose water if infant is hyperinsulimemic (i.e., infant of a diabetic mother). - Milk feeding (formula or breast) raises glucose levels, maintains stable levels, and avoids rebound hypoglycemia.

methemoglobinemia

- clinical condition in which sufficient hemoglobin in blood has been oxidized to ferric state, causing derangement in transport of oxygen and carbon dioxide. - may occur due to exposure to oxidizing agents (e.g., certain meds such as lidocaine; nitrates and nitrites) or may be result of metabolic disorders such as G-6-PD deficiency. - results in inadequate pulse oximetry readings

Bronchitis cough

- clinical diagnosis - prolonged congested cough associated with URI - thought to be due to extension of viral inflammation into lower respiratory tree and does not require antibiotic therapy. - Cough equal during the day and night, with no change in symptoms due to exercise or change in air temperature. - Additional findings may include fever and significant sputum production.

Toddler's fracture

- common injury, typically to tibia, in young walking children. - NOT sign of abuse.

Chronic Nickel Contact Dermatitis sxs, tx

- common skin condition - delayed type IV hypersensitivity reaction. - onset is usually within 24-72 hours from start of contact. - rxn can occur despite prior tolerance to exposure. Development of a rash depends on whether or not the skin barrier is intact or damaged. rash often resolves within days to weeks of avoidance. If allergy is difficult to control, some will refer to an allergist to consider "patch testing" to evaluate for nickel or other allergen leading to allergic contact dermatitis. Treatment - Avoidance of nickel, which can be found in many buttons and jewelry. - apply good emollient (such as petroleum jelly [Vaseline]) or a quality skin lubricating cream [such as Aquaphor or Eucerin]). - medium-potency topical steroid ointment (2x/day for 2weeks) may also be used to help rash to resolve.

Creatine

- daily requirement = 2 grams (half from endogenous production and half from normal diet) - seems to improve performance during brief (< 30 seconds), high intensity exercise. - s/e: WG (water retention), cramps and heat intolerance in sprinters, muscle and tendon swelling (due to water retention) predisposing to sprains, and increased BUN, creatinine and CPK. - Creatine is not recommended for patients with existing renal disease or those at high risk for renal failure.

Differential dx in children with hgb <9

- decreased marrow production: aplastic anemia - hemolytic anemia - vitamin deficiencies: folate, b12 rarer: - collagen vascular disease - malignancy - other chronic illness

Hurler syndrome

- defect in alpha-L-iduronidase - autosomal recessive lysosomal storage disease. - do not display symptoms until one year of age. - hepatosplenomegaly, coarse facial features, frontal bossing, corneal clouding, and developmental delay. - do not live past fifteen years old.

Homocystinuria

- defect in cystathionine synthase - autosomal recessive pattern. - Marfanoid body habitus, - hypercoaguable state - possible developmental delay. - Dx: by testing for increased methionine in a patient's urine or blood.

Von Gierke's disease

- defect of glucose-6-phosphatase - autosomal recessive. - get hypoglycemia, hepatomegaly, and metabolic acidosis.

Organic FTT

- diagnosed when growth failure is caused by an acute or chronic disorder that results in inadequate nutrient intake, malabsorption of nutrients, or increased energy requirements. - typically have hx and physical findings associated with underlying disease (e.g., cough, heart murmur, vomiting or diarrhea, recurrent infections, persistent rashes) in addition to poor weight gain. - Isolated poor weight gain is unusual. Ex: Congenital heart defects, Cystic fibrosis, Developmental delay with poor suck and swallow, Renal tubular acidosis, and Milk protein allergy, HIV, Vomiting caused by severe gastroesophageal reflux or bowel obstruction.

Non organic FTT

- diagnosed when poor growth does not result from an underlying disease or disorder. - ~ 90% of FTT cases are non-organic. - occasionally reflects neglect of infant (e.g., lack of food). - Less commonly, psychological basis of non-organic FTT in which stimulation is lacking because caregiver is depressed or has another mental illness, poor parenting skills, or is responding to real or perceived external stresses. - Ex: Poverty, Poor understanding of feeding techniques, Improperly prepared formula, or Inadequate supply of breast milk.

Candidal rash

- diaper dermatitis peaking - 7-10 months of age. - area of erythema in the inguinal region, as well as erythematous papules and plaques with SATELLITE lesions.

Infectious conjunctivitis: bacterial vs viral

- difficult to distinguish bacterial from viral conjunctivitis on clinical presentation. - Children < 6 likely to have BACTERIAL than a viral infection. - Get conjunctival redness and itching. - Both begin in one eye and spread Bacterial - more likely bilateral - cause a purulent exudate with eyelids crusted closed upon waking. Viral: - Adenovirus conjunctivitis frequently becomes bilateral - may be associated with pharyngitis and pre-auricular lymphadenopathy.

Early signs of shock in child

- elevated HR and RR - peripheral blood vessel constriction (causing cool, clammy extremities and delayed capillary refill time) - decreased peripheral pulses (due to vasoconstriction and decreased stroke volume). - vasoconstriction can lead to difficulty obtaining a pulse oximeter measurement - In pediatric age group, shock is NOT a diagnosis based on BP.

Testicular torsion dx and tx

- emergent urology consult - dx made mainly by clinical suspicion. - Color Doppler US or nuclear testicular scan may be useful but should not delay tx if diagnosis is evident. - Tx: surgical exploration and detorsion must occur promptly, because irreversible changes in the testis can occur within 4 hours.

Prominent epicanthal Folds

- epicanthal: skin folds of upper eyelid covering inner or medial corner of eye. - Prominent: Down syndrome, but may also be a normal finding in infants May give the eyes a crossed appearance (pseudostrabismus).

Tension headache

- episodic - worsens throughout day - mild to moderate intensity - may feel like a band around head or involve occipital area with accompanying tenderness of posterior muscles of neck

Hepatitis sxs and rf

- fever - malaise - diffuse or RUQ abdominal pain - nausea - vomiting WITHOUt diarrhea. - jaundice - change in the color of their urine. - Onset of sxs depends on etiology of hepatitis - RF: Alcohol use may either directly cause hepatitis or predispose an individual to increased risk-taking behavior and acquisition of infectious hepatitis.

Rocky Mountain spotted fever (RMSF) signs and prevalence

- fever - petechiae: tend to be on the palms and soles. - epidemiologically less likely than meningococcus unless in an endemic area.

Epiglottitis signs and sxs

- fever - stridor - drooling - dysphonia - dysphagia - respiratory distress. - Most patients appear toxic and may position their airway in a sniffing position (sitting, leaning forward, with neck hyperextended and chin protruding).

Toxic shock syndrome

- fever - sunburn-looking rash that might feel rough to the touch (like sandpaper).

Kawasaki disease signs

- fever (5 days) and a rash. - "strawberry" tongue - Dry, red, cracked lips - Diffuse erythema of the oral cavity - Erythema and/or edema of hands/feet - polymorphic truncal rash

Signs and sxs of pulmonary TB in children

- few to none, often in sharp contrast to degree of radiographic changes. - >50% of infants and children with radiographically evident disease have no physical findings and are discovered only by contact tracing. - Infants and toddlers are more likely to experience symptoms such as nonproductive cough, mild dyspnea or wheezing due to bronchial compression by enlarged regional lymph nodes. - may present with FTT - Severe cough and sputum production, together with systemic complaints (such as fever, night sweats and anorexia) usually signify intrapulmonary dissemination.

Atrial septal defect (ASD)

- first detected at 3-5 years of age. - widely split, fixed S2, which is a subtle physical finding and difficult to detect on a potentially uncooperative infant with a higher resting heart rate. - Systolic murmur due to increased flow across a normal pulmonic valve - Listening for wide splitting of second heart sound is the most helpful way to distinguish an ASD from an innocent murmur.

Ulcerative colitis

- generalized inflammation confined to mucosa, starting in rectum and involving a variable extent of colon proximally. - Crypt abscesses - Rarely, pts may have discontinuous inflammation at dx or even relative rectal sparing. Over course of the illness, however, the inflammation becomes more confluent.

CSF in bacterial meningitis

- glucose low - csf glu/blood glu: low - protein: low - wbc + pmn: elevated

Biliary Atresia

- healthy-appearing infant who develops jaundice, dark urine, and acholic (pale) stools - 3-6 weeks of age - Any infant who develops jaundice after two weeks of age must be evaluated with fractionated bilirubin (i.e., total and direct bilirubin levels). - if suspicion of biliary atresia -> refer to pediatric GI or surgery. - Tx: Kasai procedure if early (anastomosis of intrahepatic bile ducts to a loop of intestine to allow bile to drain directly into the intestine).

Incarcerated hernia def, rf, sxs, PE findings

- hernia that can no longer be reduced to its usual position with manipulation. - most present < 1 year - female predominance: ovary may be in the hernia instead of intestine. -painful - irritability is common symptom. - Vomiting and abdominal distention might occur if intestinal obstruction - PE: you will find tender mass in groin or labia majora if hernia is in inguinal region.

Roseola presentation

- high fever (38.5 to 40.5 C) for 3-5 days in a typically fairly well-appearing child, followed by abrupt resolution of fever and development of a maculopapular rash - During period of fever, some children have rhinorrhea. - bulging fontanelle: unusual physical finding of roseola, leads to evaluation for meningitis.

Asthma radiographic findings

- hyperinflation due to air trapping - increased interstitial markings - patchy atelectasis.

Ring worm

- ie Tinea corporis - Contact with animals - Scaling appearance with raised border - Pruritis - Otherwise well child

When to get an x-ray on infant that has high fever

- if there are any signs of lower respiratory tract disease - also if WBC ≥ 20,000

UTI in infant

- important cause of non-GI vomiting in children. - symptoms: non-specific; may include fever, poor feeding and vomiting, and it may lead to dehydration if not identified and treated. - unlikely to have watery diarrhea but loose stools may be seen in setting of significant infection.

Malrotation ± volvulus in infant

- may be present without volvulus (twisting of intestine on itself, causing obstruction) -> does not necessarily cause symptoms. - malrotation may result in volvulus -> vomiting and other signs of bowel obstruction. - BILIOUS emesis - Blood may be seen in stool but not typically in vomitus. - Bowel ischemia from volvulus can cause significant abdominal pain. - may present with shock, which may initially be difficult to distinguish from dehydration.

Transfusion therapy for SCD

- important to ask about blood transfusions as part of history in all children with sickling disorders, especially if patient is new to you. - Knowing about transfusions gives clues to severity of some of complications associated with SCD, and about potential for development of antibodies (alloimmunization) to minor blood-group antigens. - Blood-group minor antigens (Kell, Duffy, Kidd, etc.) are known to be clustered along racial and ethnic lines. - Exposure to blood that is cross-matched for major A, B, and O and Rh antigens may still be mismatched for minor antigens. -For patients who may be requiring transfusions with some frequency( ie SCD) it is recommended that when a transfusion is first indicated, patient have a complete RBC antigen phenotype of his own RBCs. - That way, treating physicians will know which RBC antigens patient has and does not have on his/her red blood cells, and can use blood that is "phenotypically matched" for patient's specific antigens. If this is done (and it may not be possible in an emergency transfusion), the chances of the patient developing alloimmunization to minor antigens is decreased. Benefit - Chronic transfusion therapy in children with elevated TCD blood flow has been shown to significantly decrease risk of stroke. It is not known how long this transfusion therapy needs to continue; this question is currently under study. Risks - Chronic transfusion has the risk of IRON overload, which may require the use of deferasirox or deferoxamine (iron chelators). - Chronic transfusion increases risk of alloimmunization and other transfusion reactions.

Ovarian torsion

- in any age group - more common in post-menarchal women. - STABBING Abd pain - lower abdomen or pelvic region. - n/v are also seen in majority of patients.

Hyperpnea

- increased depth of respiration without respiratory distress - may suggest a non-pulmonary condition such as fever, acidosis or extreme anxiety (hyperventilation syndrome).

Most common comorbidities in pt dx with T1DM and how to test for them

- increased risk of other autoimmune related diseases - Most common: autoimmune thyroid disease and celiac disease - Annual thyroid fx testing when metabolic control has been established for several weeks (first outpatient visit) - screen for celiac disease at dx.

Crohn's disease

- inflammation: from mouth to anus. - Mucosal TRANSMURAL inflammation may become more generalized or remain patchy and may extend gradually into SUBMUCOSA, MUSCULARIS, SEROSA. - can result in fistula formation.

Reactive arthritis causes, association

- inflammatory process associated with infection outside of joint, most often in GI or GU tract. - Classic association with urethritis and conjunctivitis is uncommon in children. - afebrile at presentatio

Zinc deficiency in child

- infrequent cause of diaper rash. - Nutritional deficiencies, such as acrodermatitis enteropathica, or malabsorption (due to cystic fibrosis, for example) can cause significant diaper rash.

Newborn Screen timing

- initial as close as possible to time of discharge and in no case later than 7 days of age. - If initial specimen is collected before 24 hours of age, a second specimen should be collected before two weeks of age.

Urticaria due to type 1 hypersensitivity

- intensely pruritic, circumscribed, raised, erythematous wheal, often with central pallor. - due to histamine release from mast cells. - Individual lesions may enlarge + coalesce with other lesions. - lesions continually change, with new lesions occurring as old ones resolve. - asymmetric. - Acute urticaria (due to type 1 hypersensitivity) affects up to 15% of population at some point in their lives. Individual lesions tend to last only 12-24 hours.

Treatment of von Willebrand disease

- intranasal or IV desmopressin. - sometimes human plasma-derived, virally inactivated von Willibrand's factor concentrate may be administered. - For menorrhagia, combination contraceptive pills, or levonorgestrel intrauterine device would be the treatment of choice.

Scabies presentation

- itching because it burrows into skin and lays eggs. - most intense time of itching is often at night. - Wrists, elbows, fingers, and toes are among the common distribution sites for scabies. - classic lesion for scabies is about a 5-10 mm curvilinear thread-like lesion--the burrow; but infants often do not have burrows on presentation.

5 Causes of Unilateral Cervical Lymphadenopathy

- kawasaki - reactive node - bacterial cervical adenitis - cat scratch disease - mycobacterial infection

Pregestimil

- made especially for infants who have protein or fat malabsorption. - typically mixed to contain 20 Cal/ounce. - protein source in the formula is fragmented rather than intact as in regular formulas and milk, and the fat source is primarily medium chain triglycerides (MCT). Both of these features make this and other similar formulas easier to digest.

Vaccinations and fever timing

- majority of adverse reactions occur in first 24 to 48 hours after first dose Ex: - rotavirus: live-virus vaccine that can cause fever in some infants, usually within first several days. - Other live-virus vaccines (MMR, varicella) produce fever in a small number of patients 7-10 days after being administered,

Signs of meningitis in an infant

- majority of infants <12 months of age with bacterial meningitis will not demonstrate a Kernig's or Brudzinski's sign, but can present with a variety of findings including: -Fever -Hypothermia -Bulging fontanelles -Lethargy -Irritability -Restlessness -Paroxysmal crying (crying when picked up) -Poor feeding -Vomiting and/or Diarrhea - neck stiffness or "nuchal rigidity."

CXR in acute chest

- may be due either to fat embolism or to vaso-occlusion of pulmonary vasculature. - Findings include, but are not limited to: a) Multilobar infiltrates (more commonly lower and middle lobes) b) Effusions c) Atelectasis

Brain stem gliomas

- may be either quite aggressive, resulting in diffuse infiltration of pons, low-grade in nature, resulting in a focal tumor in midbrain or medulla. - Low-grade gliomas: surgical resection alone required - Prognosis: quite grave to quite good

Brain tumors and incidence by age

- more common in younger age group <7yrs - incidence peaks in the first decade of life, with a second peak in older adulthood (8th decade). - Male predominance in ependymomas and medulloblastomas. 1) Supratentorial tumors: - more common tumor first 2 years of age (then infratentorial tumors predominate) - adolescence and adulthood, supratentorial tumors once again become more common. 2) Overall, childhood primary brain tumors are classified according to histology. Histologically, most common tumors are: - Medulloblastoma (20%) - Juvenile pilocytic astrocytoma (20%) - Low-grade astrocytoma (15%) - High-grade astrocytoma (7%)

Migraine headaches

- more severe than tension headaches - throbbing nature - accompanied by photophobia and/or phonophobia, abdominal pain, nausea, and vomiting - Precipitating Factors: stress bright lights, odors (such as perfumes), foods - Alleviating Factors: sleep -RF: FMH

Precordial catch syndrome

- most common cause of chest pain in adolescents (second most common is costochondritis) - cause: unknown - benign condition - sudden, sporadic onset of sharp pain, usually along the left sternal border - Exacerbated with deep inspiration. - brief, lasting seconds to a few minutes, and resolve spontaneously. - pain can often be "broken" with a forced deep inspiration. - not associated with exercise.

G6PD Deficiency

- most common enzyme problem that affects red blood cell metabolism worldwide. - XR - more than 100 distinct enzyme variants of G6PD associated with a wide spectrum of hemolytic disease. One of these variants in Greek babies can be a cause of hyperbilirubinemia and potential kernicterus. - Risks during nursing: Fava Beans, drug triggers

CAH in newborn

- most common form = 21-OH deficiency - decreased production of cortisol and aldosterone. - elevated plasma 17-OH progesterone -> diverted to androgen formation. - female patients virilized - male patients harder to detect (get increased penile length, darker pigmentation of scrotum). - Decreased mineralocorticoid activity in 21-OH deficiency (salt-wasting form) leads to hyponatremia and hyperkalemia - may present with vomiting, dehydration, and shock in a newborn.

vWF Epidemiology

- most common hereditary bleeding disorder. - Occurs in approximately 1% of the population. - autosomal dominant inheritance with variable penetrance (Type 1 and all Type 2 subcategories). The much less common Type 3 is inherited as autosomal recessive.

Generalized tonic clonic seizure

- most common type seen in children. - begins abruptly with tonic (rigid) stiffening of all extremities and upward deviation of eyes. - Clonic jerks of all extremities follow tonic phase. - Finally, child becomes flaccid, and urinary incontinence may occur.

Congenital hypothyroidism

- most look normal at birth because hypothyroid fetus partially protected by maternal thyroid hormone. - Feeding problems -Decreased activity - Constipation -Prolonged jaundice -Skin mottling -Umbilical hernia Infants born to mothers with Grave's disease treated with antithyroid drugs may also have transient hypothyroidism. Worldwide, iodine deficiency is the most common cause of hypothyroidism at birth. More prevalent in latino population typically primary hypothyroidism

Osteomyelitis causes, sxs in a child

- most often caused by S. aureus (before era of routine immunization,HIB) - usually presents with pain and refusal to bear weight (when affecting a leg bone). - history of fever is present in 50% cases - Because indolent presentation, dx can be delayed by up to 5 to 10 days. - Osteomyelitis in ilium may present with hip pain.

Vesical ureteral reflux

- most reflux either Grade 1 or Grade 2=very high rate of spontaneous resolution; most cases resolve within 2-5 years. - Grades 4 and 5 VUR less common, but not likely to resolve. Needs surgery. - When to refer: patients with Grades 1-2 VUR followed by PCP, grades 3-5 to urologist. - Surgical Repair of VUR: endoscopic injection of material in the area where ureter enters bladder and reimplantation of ureter into bladder. - can consider prophylactic antibiotics.

Dyskinetic CP associations

- motor abnormalities throughout body - kernicterus association - perinatal asphyxia - basal ganglia pathology - can involve thalamus and cerebellum on imaging.

SJS

- mucocutaneous disorder - Get fever, severe stomatitis (inflammation of the mucous lining of any of the structures in the mouth), conjunctivitis, and a blistering rash. - typically precipitated by medications or infections.

Stevens-Johnson syndrome

- mucocutaneous disorder caused by a hypersensitivity reaction to medications, infections, or other illnesses - Severe, pruritic rash (erythema multiforme) - Fever (not expected to last 7 days) - Mucosal changes (e.g., stomatitis) - Conjunctivitis

Jitteriness in a newborn

- mvts= stimulus-sensitive - generalized symmetric - can be diminished by gentle, passive flexion of the limbs.

Adverse Effects of Prenatal Substance Use: alcohol

- no "safe" amount of alcohol to prevent FAS - FAS: distinct pattern of facial abnormalities, growth deficiency, and evidence of central nervous system dysfunction. - cognitive disability - poor motor skill, poor hand-eye coordination - learning problems (i.e., difficulties with memory, attention, and judgment).

HSP signs and sxs

- non-thrombocytopenic purpura. - 1/3 of children with HSP have renal involvement, most common manifestation of which is hematuria. - Renal involvement is less common in children < 2 yrs (about 25% in that age group). - Arthritis or arthralgia, mainly of knees and ankles, is seen in about 75% of children with HSP. - Colicky abdominal pain is present in 65% of patients. ~ 50% of children with HSP may develop intestinal bleeding, with guiaic positive stool.. - 2/3s of patients report a recent upper respiratory tract infection.

Pityriasis alba

- nonspecific dermatitis characterized by patches of hypopigmentation on face, neck, upper trunk, and proximal extremities. - Lesions range from 0.5 to 5 cm in diameter with well-defined, irregular borders and fine scale. - Associated with sun exposure. - May be mistaken for tinea versicolor.

When can you do a CMP, Calcium in a newborn?

- not recommended soon after birth because newborn's levels reflect mother's status as well as effect of medications administered to mother during labor. - Results at age 12-24 hours are more indicative of the infant's status.

Polycythemia in newborn

- occurs when hematocrit is above normal limit for gestational age (usually defined as >65% in a term newborn). -Many infants are asymptomatic, and hcts are not routinely checked in newborns. If sxs: - Can have altered mental status, poor feeding - plethora (excess of blood in circulatory system or in one organ or area) - acrocyanosis - hyperbilirubinemia. - Occurs in the first few hours to days of life.

VSD surgery

- on cardio-pulmonary bypass. - Most VSDs can be closed via an incision in right atrium (a right atriotomy). - VSD is behind the septal leaflet of the tricuspid valve, which must be retracted. A prosthetic patch is then sewn over the defect on the right side of the septum, taking care not to damage the conduction system, which is very close to where the patch is placed.

Timing of Neonatal Screen

- optimal time for testing is ≥ 24 hours after birth. - specimen obtained before 24 hours of age may miss PKU and other disorders with metabolite accumulation. - first specimen is obtained prior to 24 hours, a second specimen should be obtained in next one to two weeks.

Oxygen challenge test

- oxygen will increase PaO2 of infant whose cyanosis is caused by a respiratory condition - will not significantly increase PaO2 if a cardiac lesion causes cyanosis.

In utero circulation

- oxygenated blood from placenta --> umbilical vein --> a) A portion of this blood perfuses liver. b) remainder bypasses liver through ductus venosus --> IVC. i) 1/3 to PFO --> LA and is pumped to coronary, cerebral and upper body circulations. ii) 2/3 combines w/ venous blood from upper body in RA, and is directed to the RV --> pulmonary artery. In utero, vasoconstriction of pulmonary arterioles produces high pulmonary vascular resistance, allowing only 8-10% of blood from the RV to flow through pulmonary vasculature. Remainder, 90-92%, is shunted through PDA to descending aorta.

Functional Abdominal Pain def, causes, dx and tx

- pain that is "without demonstrable evidence of pathologic condition such as an anatomic, metabolic, infectious, inflammatory, or neoplastic disorder." - enteric nervous system thought to be in crisis with CNS -> dysregulation -> pain. - may have abnormal bowel reactivity to physiologic stimuli (meal, gut distension, hormonal changes), noxious stressful stimuli (inflammatory processes), or psychological stressful stimuli (parental separation, anxiety). Dx: - by pcp in children 4-18 years of age with chronic abdominal pain, without requirement of additional diagnostic evaluation when: - no alarming sxs or signs - PE nl - stool sample tests negative for occult blood. It is not uncommon for children with functional abdominal pain to have additional somatic complaints, such as headache, difficulty sleeping, or limb pain. Tx - reassurance - Occasionally a child's fear of going to school or another phobia may be so strong that removal of pain as defense mechanism may only lead to other symptoms. These children should be followed closely and referred for psychological evaluation and tx

Breast Milk Nutrients

- perfect balance of carbs, fats (lipids), proteins for human infants. - provides antibodies, oligosaccharides, lactoferrin, lysozyme, growth factors, bifidobacteria, and other non-nutritive substances that protect against infection and promote growth. - non-nutritive substances are especially concentrated in colostrum - Carbs: lactose as major carbohydrate. Lactose intolerance is uncommon in the first year of life. - Lipids: ~ 50% of calories in human milk come from lipids. Lipid concentration in breast milk increases as the nursing episode proceeds; therefore, it is important that an infant empty the breast before going to the next breast. - Approximately 50% of calories in human milk come from lipids. - lipid concentration in breast milk increases as nursing episode proceeds; therefore, it is important that an infant empty the breast before going to the next breast. - Protein: mostly whey protein

Intussiception dx and tx

- perform an air or barium enema. - US has increasing utility in initial evaluation. - Once visualized, telescoped segment of bowel is reduced by air or hydrostatic pressure. - Occasionally, procedure is unsuccessful and patients require surgical reduction.

Zellweger syndrome

- peroxisomal disorder - generally hypotonic - poorly responsive.

Cough variant asthma

- persistent nocturnal cough may be only manifestation of their asthma. - seen especially in young children. - Because this frequently occurs at night, examinations during the day may be normal.

Newborn Screening

- phenylketonuria (PKU)** - congenital hypothyroidism** - Maple syrup urine disease - congenital adrenal hyperplasia - galactosemia - sickle cell disease

Adverse Effects of Prenatal Substance Use: cocaine

- placental insufficiency - low birth weight. - may lead to subtle, yet significant, later deficits in some children: of cognitive performance, information-processing, and attention to tasks—abilities that are important for success in school.

Bacterial causes of periorbital cellulitis

- pneumococci - Moraxella catarrhalis - non-typable Haemophilus influenzae - Incidence of HIB has dropped markedly since vaccine

Signs of "toxic child"

- poor or absent eye contact. - Fails to recognize caregivers. - very irritable and cannot be consoled or distracted. - minimal response to painful procedures, such as IV placement or blood draw. - signs of poor perfusion or respiratory distress.

Lethargy in an infant

- poor or absent eye movements or - failure of a child to recognize parents or to interact with persons or objects in environment.

Leukocyte Esterase Test

- positive leukocyte esterase reaction detects esterases released from broken-down leukocytes. - indicates presence of WBCs in urine, but pyuria can be seen in a variety of conditions in addition to urinary tract infection. - insufficient to make the diagnosis of UTI

Nitrite Test

- positive nitrite test occurs when gram-neg bacteria, which can reduce urinary nitrate into nitrite, are present in urine (esp. E. coli, Klebsiella, and Proteus spp) for adequate amount of time (3-4 hours). - Highly specific for presence of bacteria in urine (few false positives). - A negative nitrite, however, has a very poor sensitivity (lots of false negatives) for bacteruria, especially in young infants who urinate frequently.

Diagnosis of Congenital Toxoplasmosis

- positive toxoplasma-specific IgM, IgG, or IgA assay in newborn period - get increasing IgG titers in first year - or persistently positive IgG titers beyond the first year of life.

Fluid Therapy for Severe Dehydration

- primary recommended mode of therapy for severe dehydration is to provide volume restoration via IV bolus therapy with isotonic saline solution. - Repeated boluses of normal saline or LR solution, in 10-20 ml/kg aliquots, are given (reassessing after each bolus) until patient has improved to only mild dehydration or normal fluid status. - Rehydration can then be completed either orally or with ongoing IV fluids.

vWF diagnosis

- prolonged platelet function or bleeding time and mild prolongation of the aPTT point to diagnosis of vWD. - BUT aPTT may be normal and patient will still have vWD. - To confirm vWD, check the von Willebrand's factor antigen and/or platelet function analysis and factor VIII levels.

ECG findings in patient with large VSD

- prominent biventricular forces (high voltage QRS complexes in leads V1 and V2) suggesting both LV volume overload and RV pressure overload. - RVH due to RV pressure overload (pulmonary hypertension). Can see upright T wave in lead V1, which is an additional sign of RVH.

Who is considered high risk for meningococcal infection?

- pts with complement component deficiency or functional or anatomic asplenia - Individuals who are part of a community outbreak - Those who are traveling internationally to a region with hyperendemic or endemic meningococcal disease

Eisenmenger's syndrome

- pulmonary vasculature constricts in response to exposure to high pressure and high flow. With chronic exposure to these conditions pulmonary vasculature will develop permanent changes and loses ability to relax. - Get: pulmonary vascular resistance to exceed the systemic resistance, and shunting through the VSD will shift from left-to-right to right-to-left. - Get: cyanosis, progressing to polycythemia, HF, and death. Most patients with Eisenmenger's syndrome live into their twenties, but with a very impaired quality of life. - Patients with a large unrepaired VSD universally develop Eisenmenger's syndrome, but typically not before 6 months of age.

Varicella

- rash starts on TRUNK, spreads to extremities and head. - erythematous macule -> papule -> vesicle to pustule-> crusts over. - Lesions at various stages of development are seen in same area of body. - usually a mild fever. - disease is self-limited - 1 week.

Evaluation of generalized edema in a child

- renal fx: Electrolytes, BUN and Cr - AST/ALT - cholesterol - albumin - TG - C3 and C4 complement levels Streptozyme (+ in setting of post strep glomerulonephritis)

SSRI OD

- requires significant overdose - overdoses cause serotonin syndrome: profuse sweaty skin, agitation, fever, mental status changes, diarrhea, myoclonus, hyperreflexia, ataxia, shivering.

Viruses associated with AOM

- respiratory syncytial virus (RSV) - influenza - rhinovirus.

Periventricular leukomalacia (PVL)

- result of damage to white matter surrounding ventricles in brain - from: hypoxia, ischemia, and inflammation. - associated with: intraventricular hemorrhage (bleeding from delicate vessels of neuronal and glial proliferation zone—germinal matrix—that surrounds lateral ventricles in preterm infants and fetuses) -likely that damage to white matter is actually more widespread, but not easily visualized using current clinical imaging techniques.

Persistent Pulmonary Hypertension of the Newborn (PPHN): def, causes, signs

- result of elevated pulmonary vascular resistance to point that venous blood is diverted to various degrees through fetal channels (ductus arteriosus and foramen ovale) into systemic circulation and bypasses lungs, resulting in systemic arterial hypoxemia. - can result from several conditions: meconium aspiration syndrome, diaphragmatic hernia, hypoplastic lungs, in utero asphyxia. - Following findings may indicate that an infant has PPHN: a) Tachypnea b) Tachycardia c) Respiratory distress, with findings such as expiratory grunting and nasal flaring d) Generalized cyanosis e) Low oxygen levels, even while receiving 100% oxygen

Nystagmus

- rhythmic oscillation of the eyes - May occur in one or more planes (horizontal, vertical or rotary). - defined by its quicker phase. - sign of cerebellar disease, and has many possible causes: tumors, toxins, cerebellitis and multiple sclerosis. - When nystagmus occurs because of cerebellar disease, most prominent when patient is looking TOWARDS side of lesion.

Tinea capitis

- ringworm of the scalp. - Systemic tx: griseofulvin - Because the fungus grows slowly and is killed in the replication phase, it needs to be treated for an extended period of time--usually six to eight week - treatment should continue after it appears better to prevent recurrence. - alternative therapies: terbinafin, itraconazole. - Be on watch for a significant allergic response: "kerion" (inflamed, weeping, boggy lesion that often requires treatment with oral steroids; although once fungal infection in under control, reactions go away).

Tx moderate acne

- same initial tx should be used with addition of another product. - Antibiotics - topical antibiotic like clindamycin or erythromycin (abx active against P. acnes), - Topical prescription products exist in combination form or may be used in combination. - Options for oral therapy include antibiotics such as doxycycline or tetracycline, or contraceptive pills (for females).

Pityriasis rosea

- scaly papules and plaques in the hallmark "christmas tree" distribution on back and trunk, following the lines of skin cleavage. - Lesions may also be found on the upper thighs and in the groin area. - initial lesion, called the "herald patch," is usually largest scaly plaque with a raised border and can easily be confused with tinea corporis.

Complications of scabies

- secondary infections: impetigo or even cellulitis. - secondary eczematous dermatitis may also be involved.

Tx severe acne

- see dermatologist. - oral isotretinoin.

Nasal flaring

- seen in small children with significant respiratory distress - indicates that accessory muscles are being used for respiration.

Vasovagal Reflex

- self-limited systemic hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or peripheral vasodilation. - Children frequently describe prodromal symptoms: dizziness, lightheadedness, sweating, nausea, weakness, and visual changes.

Turner syndrome

- sex chromosomal disorder most likely to be associated with physical differences at birth. - ~ 99% of conceptuses with Turner syndrome miscarry, most in the first trimester. - lymphedema in utero, which is the cause of many of the physical findings such as: Webbed neck, low ear placement, edema of hands and feet, hyperconvex nails,"shield" chest, w/ widely spaced nipples Additional findings in Turner syndrome: - Coarctation of aorta found in ~20% of affected girls. - Short stature is common, and some girls are not diagnosed until early adolescence when they present with short stature and delayed sexual maturation (due to gonadal dysgenesis). - Most have a normal IQ.

Inborn error of metabolism in an infant

- should be considered, particularly in infants with recurrent emesis. - sxs may be triggered by intercurrent illness such as gastroenteritis or infections. - may present with diminished oral intake for a variety of reasons, including lethargy and irritability. - Metabolic disorders may also present with shock, which may be difficult to distinguish from severe dehydration.

Head bobbing

- sign of respiratory distress in young infants is head bobbing, which is also due to use of accessory muscles of respiration (neck strap muscles). - In synchrony with each inspiration, head is noted to bob forward owing to neck flexion caused by use of neck strap muscles. - best observed during sleep.

Grunting

- sign of respiratory distress seen in infants, - forced expiration against partially closed glottis - thought to help infants generate the positive pressure necessary to stent airways open.

"Asthma" vs. "Reactive airways disease" (RAD)

- significant proportion of children with wheezing that presents early in life do not continue to wheeze beyond 2 to 3 years of age. - Some physicians prefer to use term "reactive airways disease" when children appear to have signs and symptoms of underlying airway hyperresponsiveness that is characteristic of asthma, but in whom a diagnosis of asthma is not yet definite. - use of this term has been somewhat controversial, and its validity as a distinct diagnosis has been questioned.

Most common cause of Congenital hypothyroidism

- some form of thyroid dysgenesis: a. Aplasia b. Hypoplasia or c. ectopic gland: accounts for 2/3 of thyroid dysgenesis.

spastic quadriplega

- spasticity, clonus, and exaggerated tendon jerks throughout their bodies (often greater in legs>arms) - Imaging would show global brain abnormalities. - MRI: periventricular white matter abnormalities thought to be due to ischemia.

Niemann Pick Disease

- sphingomyelinase - lysosomal storage disease. - present by six months of age with hepatomegaly, ataxia, seizures, and progressive neurologic degeneration. - Fundoscopic exam reveals a "cherry-red" macula.

Kernicterus

- staining of basal ganglia and cranial nerve nuclei by bilirubin. - also describes clinical condition that results from toxic effects of high levels of unconjugated bilirubin.

Supplementation with Iron

- starting at age 6 months. - Most standard formulas are iron-fortified.

If a child has diarrhea with high fevers

- stool guaiac and fecal leukocytes - if these are positive then obtain stool cultures.

spastic hemiplegia

- stroke damaging unilateral upper motor neuron tract - should present with spasticity of contralateral arm and leg, not entire body.

cephalohematoma

- subperiosteal hemorrhage - localized to cranial bone that was traumatized during delivery. - DOES NOT extend across a suture line.. - As the blood is reabsorbed from the cephalohematoma it will contribute to hyperbilirubinemia.

Aplastic crisis

- temporary inhibition of erythroid production frequently associated with viral illness,(arvovirus B19) - Because of the baseline rapid destruction of RBCs and baseline lower hct in patients with sickle cell disease, brief inhibition of RBC production produced by viral infection can have far greater consequences than in patients with normal red blood cell survival.

Treatment of scabies

- two applications of permethrin 5% cream, one week apart, for all affected household members. - cream is applied at night before bed and washed off in morning, or after around 8-12 hours. - adult: apply the cream from the neck down. - infants: entire body should be covered from hairline down, including behind the ears, being careful to avoid the areas around the eyes and mouth. - After bathing, wash all bed linens and clothing worn during treatment. - "post-scabetic itch": may persist for a few weeks after mites have been killed and is due to persistent inflammation from infestation. A moderate potency topical steroid and OTC diphenhydramine may be helpful. Sometimes families need to be re-treated or discover there was another hidden exposure. If there is an allergic response to permethrin—or if it does not work—oral ivermectin is often effective, although currently not approved by the FDA for children under 15 kg.

Oral isotretinoin

- tx of severe nodulo-cystic acne. - Reduces sebum secretion,--> decreasing P. acne proliferation. - anti-inflammatory. - s/e: chance of depression, hypertTG, hepatitis, decreased night vision, photosensitivity). - Most serious potential risk is teratogenicity: Prescribers and patients must be registered with pledge program, and patients must meet all the requirements.

HSP treatment

- tx with steroids remains controversial - may confer benefits in reducing gastrointestinal manifestations. Systematic reviews have not demonstrated a consistent benefit for corticosteroids in preventing serious renal involvement. There is a need for a high-quality multicenter, randomized controlled trial to help us understand the potential benefits of early corticosteroids for children HSP.

Klinefelter syndrome

- typically normal appearing at birth - may not be diagnosed until adulthood. - infertility due to testicular atrophy. - eunuchoid body habitus - gynecomastia in adolescence. - IQ varies, but is usually in the low-normal - no specific phenotype for either 47, XXX (dev delay more common) or 47, XYY (taller than avg, IQ low nl. - behavior pbs increase

Who Can Have an IO Line Placed?

- typically reserved for infants and children 6 years of age or younger. - Although IO access has been used in older children and in adults, it becomes progressively more difficult to do because cortex of bone becomes thicker and tibial bone marrow cavity becomes smaller. - IO line should be discontinued as soon as other vascular access has been achieved

Basilar migraine

- uncommon - young women or children - first develop visual phenomena like those of typical migraine except that BILATERAL - transient cortical blindness may also occur. - Can have: Vertigo, ataxia, Incoordination of the limbs, dysarthria, bilateral limb and perioral paresthesias. - Sometimes followed by transient loss or impairment of consciousness or by a confusional state. - Impairment in consciousness: followed by throbbing HA (occipital) often with nausea and vomiting.

Pneumonia sxs in children

- uncommon but important case of abdominal pain in young children. - Irritation of pleura by a lower lobe infection causes pain. - Cough, difficulty breathing, rhinorrhea, and chest pain

Epiglottitis def, epidemiology

- uncommon thanks to widespread immunization - life-threatening emergency that has historically almost always been due to infection with Haemophilus influenzae type b (Hib). - now rare cases more commonly due to staphylococcal or streptococcal organisms than Hib. - presents most often in children between the ages of 2 and 5 years.

Testicular torsion sxs, PE

- urologic emergency in which goal is to save affected testis. - Usually occurs in early adolescence - Presents w/ acute onset of severe hemi-scrotal pain, n/v - PE: enlarged tender testis, scrotal edema, and absence of cremasteric muscle reflex.

Ballard Gestational Age Assessment Tool

- uses signs of physical and neuromuscular maturity to estimate gestational age. - can be particularly helpful if there is no early prenatal ultrasound to help confirm dates, or if gestational age is in question because of uncertain maternal dates.

Treatment of cellulitis

- usually caused by S. pyogenes or S. aureus. -Tx with a first-generation cephalosporin (such as cefalexin) OR semi-sythenthetic penicillin with a beta-lactamase inhibitor (amoxicillin-clavulonate) if there is no concern for MRSA. -Clindamycin or BACTRIM would be appropriate treatment for cellulitis caused by MRSA.

Kawasaki disease

- vasculitis - Fever > 5 days - Nonpurulent conjunctivitis (may have cleared prior to presentation) - Rash - Swelling and erythema of extremities

Scarlet fever rash and sxs

- very fine papules, often described as feeling like SANDPAPER. - BLANCHING erythematous - starts in the GROIN, AXILLAE, and NECK, but rapidly spreads. - fever can be high, - self-limited disease, lasting <10 days. - IMPT to treat with abx to prevent non-suppurative complications of strep, including rheumatic fever.

Common causes of wheezing in infants and toddlers (4)

- viral bronchiolitis - asthma - foreign body aspiration - GE reflux

HSP complications

- ~ 5% of children with HSP progress to chronic renal failure. - <1% will develop end-stage renal disease. - Although HSP is considered a benign childhood disease, it occasionally requires hospitalization for management of severe abdominal pain, GI bleeding, intussusception, and renal involvement.

PKU

-AR - deficiency in enzyme phenylalanine hydroxylase. - vomiting - HYPOTONIA, - microcephalY - progressive cognitive impairment, including seizures. - albinism - musty odor of sweat and urine (due to phenylacetate).

Tetravalent Meningococcal Conjugate Vaccine (MCV4)

-For general population, MCV4 is given to children ages 11-18. - Normally given IM during the routine preadolescent immunization visit (at 11-12 years). - Give booster dose at age 16. For adolescents who receive first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 through 18 years, before peak in increased risk. Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose. 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.

Why are children at higher risk for dehydration?

-Higher surface area:body mass ratio; hence, a greater relative area for evaporation to occur - Higher basal metabolic rates than adults, which generates heat and expends water, and - Higher percentage of body weight that is water (in infants, 70% of body weight is water; in children, 65%; and in adults, 60%). - Because of this, children under 4 years of age have a particularly increased risk of dehydration

Idiopathic Intracranial HTN

-Increased ICP in absence of intracranial mass lesion or hydrocephalus - often mimics brain tumors in presentation. - Thought to occur because of alterations in CSF absorption and/or production, or abnormalities in vasomotor control and cerebral blood flow. - Get: HA, vomiting, diplopia secondary to paralysis of CNVI - Complication: blindness

Nortriptyline Toxicity Dose and peak effect

-Ingestion of 2.5 mg/kg+ in a 2-year-old will cause significant symptoms. - Peak effect: 7-8 hours after ingestion.

What must ALWAYS be considered in a child refusing to walk?

-LEUKEMIA - Replacement of bone marrow by leukemic cells can cause bone pain that presents as limp, refusal to walk, or localized discomfort of the jaw, long bones, vertebral column, hip, scapula or ribs. - sxs may precede systemic signs such as fever and weight loss.

Ectopic pregnancy findings

-PE may be completely normal in early, unruptured ectopic pregnancy - More rarely: diffuse abdominal tenderness, adnexal or cervical motion tenderness may also be seen. - Mild enlargement of uterus may be present. - Fever NOT usual characteristic of an uncomplicated ectopic pregnancy.

Signs and sxs of untreated hypothyroidism

-Prolonged jaundice - Lethargy - Large fontanelles -Macroglossia (enlargement of the tongue) - Umbilical hernia -Constipation -Abdominal distention - Severe developmental delay

Paradoxical breathing

-almost always a sign of very severe respiratory distress due to respiratory muscle fatigue - occurs when force of contraction generated by the diaphragm exceeds ability of chest wall muscles to expand the rib cage. As a result, the chest is drawn inward with inspiration, and the abdomen rises due to downward displacement of abdominal contents. - seen more commonly in infants and young children than in older individuals due to the greater compliance of the chest wall.

Children of teen parents are more likely to (4 things):

-have health problems -become incarcerated -become teen parents themselves -be unemployed

Guildelines for referral to an asthma specialist

-life-threatening asthma exacerbation. - not meeting goals of therapy after 3-6 months of tx, or earlier if the child appears unresponsive to tx. - Signs and sxs are atypical. - Other co-morbid medical conditions complicate asthma management. - Additional testing needed (i.e., allergy testing, bronchoscopy) or immunotherapy being considered. - Additional patient education regarding adherence to medications or allergen avoidance. - Patient is young (< 3 years old) or has severe asthma.

Bochdalek hernia

-located posterolaterally -most common of congenital diaphragmatic hernias (95%)

4 Risks for Infants of Adolescent Mothers

-lower birth weight -vertically acquired STIs (due to higher incidence of STIs in adolescent population) -poorer developmental outcomes -increased risk of fetal death

How do red blood cells of newborn differ from adult red cells?

-much lower number of reactive A or B sites. - This is why the Coombs test may be read as weakly positive in ABO hemolytic disease, and may also explain the fact that red-cell life span in infants with ABO hemolytic disease is only slightly shortened.

How does VSD cause CHF?

-ninfant with a VSD is supplying enough blood to tissues to meet body's metabolic needs, but is doing so from an elevated filling pressure (due to LV volume overload). - The adequate cardiac output is achieved by creating a high adrenergic state and by activating the renin-angiotensin system. Many of the symptoms of CHF in the infant are caused by these neurohormonal changes.

Febrile seizure

-occur in children ages 6-5yrs at a frequency of 2-5% - occur on first day of febrile illness, often as first sign to the parents tha child is ill. - Fever > 38 C is typically present. - Children are developmentally normal and often have a +FMH - more are generalized.

Absence epilepsy

-~ 3 years. -loss of environmental awareness ("staring off into space") - automatisms (e.g., eye-fluttering or lip-smacking). - generalized seizures - children usually regain consciousness more quickly than post-ictal phase seen in a generalized tonic-clonic seizure. - NOT associated with loss of tone or urinary continence. - can be precipitated by hyperventilation or photic stimulation.

Intraosseous Access

.- IO needle inserted into marrow cavity of long bone. - Substances then injected into bone marrow, where they are absorbed almost immediately into general circulation - Used in life-threatening situations - Intraosseous infusion is possible because veins that drain medullary sinuses in bm do not collapse in children with shock or hypovolemia. - Blood draining from bone marrow of tibia enters general circulation via the popliteal vein, and branches of the femoral vein drain the medullary sinuses of the distal femur. - Typical sites used: distal femur**, proximal tibia**, distal tibia, or iliac crests.

Good and bad ways of assessing circulation

1) HR: very sensitive measure of volume status. FIRST and most subtle sign of possible inadequate perfusion. 2) Capillary refill time: is also a sensitive sign of hypovolemia. 3) NOT sensitive: BP. Body's protective mechanisms maintain blood pressure, so hypotension is typically a late sign of shock. Also, checking a patient's extremities is NOT a good way to assess circulation. If a patient is cold, her hands and feet can feel cold even if her circulatory status is fine. In addition, emergency departments are frequently cold, and a child's hands and feet can rapidly become cold to the touch.

Bacterial causes of acute otitis media

1) Haemophilus influenzae, nontypeable 15-52% 2) Streptococcus pneumoniae 25-50% 3) Moraxella catarrhalis 3-20% 4) Streptococcus pyogenes < 5%

CMV sequelae

1) Hearing loss: onset of hearing loss may be after the newborn period; loss is often progressive. 2)Microcephaly + intracranial calcifications: associated with an increased risk of CNS sequelae of congenital CMV infection, such as developmental delay. 3) Intellectual disabilities and/or cerebral palsy. 4) Hepatosplenomegaly/Rash: nonneurological neonatal clinical abnormalities can be expected to RESOLVE spontaneously within weeks.

Studies for the Evaluation of a Cyanotic Newborn

1) ABG 2) Blood and CSF cultures if suspect sepsis 3) CBC with differential: to rule out neutropenia, leukopenia, abnormal immature-to-total-neutrophil ratio, and thrombocytopenia as signs of sepsis. 4) CXR 5) Echocardiogram: Gold std in dx of congenital cardiac lesions and PPHN. - when there is persistent cyanosis and no indication of lung disease, or when there are other signs suggesting a heart defect, such as a murmur, abnormal ECG or acxr showing an abnormal cardiac contour. 6) Oxygen challenge test (hyperoxia test) to differentiate between cardiac and pulmonary etiology in cyanotic infants. 7) Physical examination - Critical to identify heart murmurs and respiratory findings that might be cause of cyanosis. - some murmurs may not be present early in life because of the elevated pulmonary vascular pressure. 8) Pulse oximetry

Tx Kawasaki disease

1) ASPIRIN - High-dose aspirin (80-100 mg/kg/day, divided into four doses) for anti-inflammatory properties. - shortens febrile course of illness but has no effect on development of aneurysm. - Following defervescence, low-dose aspirin (3-5 mg/kg/day given in a single dose) is administered for its anti-platelet effects. - Aspirin id/ced after total of 6-8 weeks if no coronary artery changes are seen in follow-up echocardiograms. If there are coronary artery abnormalities, low dose aspirin is continued indefinitely as an anti-platelet agent. 2) IVIG - decreased incidence of coronary artery aneurysms from 20-25% to 2-4%. - single dose of IVIG at a dose of 2 g/kg administered over 10-12 hours has been shown to be more effective in reducing risk of coronary artery aneurysms than multiple lower doses Note: use of ibuprofen has been shown to antagonize the irreversible platelet inhibition induced by aspirin and therefore should be avoided in children with coronary aneurysms taking aspirin for its antiplatelet effects. - role of steroids is unclear. For years, steroids were felt to have no role, or even to be detrimental. Newer studies suggest that they may have a role in the acute management, and additional information is needed

Diff dx of respiratory distress and feeding difficulty in an Infant

1) CHF: often present with a history of respiratory distress, difficulty feeding and FTT 2) Respiratory infection: bronchiolitis or pneumonia, present with respiratory distress, typically also with fever. 3) Sepsis: early signs of sepsis can be subtle and non-specific, including lack of fever. 4) Metabolic disorder: Most are tested for on newborn screening

Admission orders for DKA

1) Continuous monitoring of vitals • 2) Q1H neuro checks for cerebral edema 3) I/Os 4) Insulin: continue on the insulin drip until acidosis has resolved (bicarbonate > 15 mEq/L or a normal anion gap) and patient is ready to transition to subcutaneous insulin. 5) Serum glucose Q1H 6) Serum Ca, Mg, and phosphorus (since often depleted). As phosphorus is added, calcium must be monitored, too. 7) Serum pH (VBG) every 60 minutes 8) Urine dipstick for ketones - Other good parameters to follow are serum bicarbonate, anion gap, and urinary and/or serum ketones.

Treatment of CHF in newborn

1) Furosemide (Lasix): relief of sxs, counteract fluid retention that occurs as a result of activation of the renin-angiotensin system. 2) Digoxin: shown in some studies to improve sxs in infants with CHF due to a VSD. Mechanism responsible for the clinical improvement is not altogether clear, as infants with a VSD do not have impaired contractility. 3) Enalapril BID or captopril TID: afterload reduction with ACE inhibitors will decrease systemic vascular resistance and promote forward flow of blood from the left ventricle rather than flow through the VSD to the pulmonary vasculature. Increasing Caloric Intake Another consideration is to optimize feeding by fortifying expressed breast milk or formula to provide greater caloric density.

TORCH infection tests

1) Hepatitis B: Maternal hepatitis B surface antigen (HBsAg) 2) Rubella: Maternal and infant rubella titer 3) Toxoplasma: Infant toxoplasma titer 4) CMV: Infant urine culture

Risks for SGA Newborns

1) Hypoglycemia: - due to decreased glycogen stores, Heat loss, Possible hypoxia, Decreased gluconeogenesis. - Commonly asymptomatic, though may exhibit poor feeding and listlessness 2) Hypothermia: - due to Cold stress, Hypoxia Hypoglycemia, Increased surface area Decreased subcutaneous insulation - Commonly asymptomatic, though may exhibit poor feeding and listlessness 3) Polycythemia - due to Chronic hypoxia, Maternal-fetal transfusion - Get: "Ruddy" or red color to skin, Respiratory distress*, Poor feeding, Hypoglycemia - *Infants with sluggish blood flow (hyperviscosity syndrome) because of a critically elevated hemoglobin/hematocrit may have respiratory distress secondary to inadequate oxygenation of end-organ tissues.

Most common causes of shock in kids

1) Hypovolemic (hemorrhage, diarrhea/dehydration) 2) Septic shock

3 Brain Imaging Findings in Congenital CMV

1) Intracranial calcifications (appear as bright areas) on CT 2) Diminished # of gyri + abnormally thick cortex (lissencephaly or agyria-pachygyria) 3) Enlarged ventricles

Evaluation of Neonatal Hyperbilirubinemia

1) Maternal ABO + Rh typing and screen for unusual isoimmune antibodies 2) Infant (cord blood) ABO + Rh typing, and direct Coombs' test 3) G6PD screen 4) Total serum bilirubin (TSB)- If jaundice is noted in the first 24 hours of life or with significant jaundice. 5) Direct bilirubin level and/or urine dipstick for bilirubin. Give if infant has dark urine or light stools, persistent jaundice (> 3 weeks), or if infant is ill (there will be an increased direct bilirubin with sepsis/congenital infection). 6) CBC or hgb level: If there is a suspicion of hemolytic disease or anemia (e.g., jaundice in the first day of life or TSB >14 mg/dL in the first 48 hours). -If anemia is found, elevated reticulocyte count would be further evidence of hemolysis (some might obtain a reticulocyte count with the CBC). 7) Reticulocyte count and blood smear 8)Neonatal screening 9)Tests for newborn sepsis: CBC and diff cell count, crp, blood cultures, LP with chemistry and cultures 10)Tests for congenital infections (TORCHS titres)

Factors Limiting Fetal Growth in Utero (maternal, uterine, fetal)

1) Maternal factors - Poor weight gain in the third trimester - Preeclampsia - prescription or illicit drug use - Maternal infections 2) Uterine abnormalities - Placental abnormalities - Placenta previa - Placental abruptions - Abnormal umbilical vessel insertions 3) Fetal abnormalities - Fetal malformations - Metabolic disease - Chromosomal abnormalities - Congenital infections

Complications of brain tumors (5)

1) Neurocognitive defects 2) ADD 3) Learning disabilities 4) Endocrine abnormalities 5) Stroke.

Evaluation for Foreign Body Aspiration

1) PA and lateral chest films 2) Bilateral decubitus or inspiratory/expiratory chest films: to evaluate whether obstruction of larger airways, such as that due to a foreign body, is present. 3) Chest fluoroscopy: excellent radiographic test to evaluate for airway foreign body in an infant or toddler because it does not require child to hold breath. Also, it is a dynamic evaluation that allows visualization of airways over several breaths rather than a single breath, as is case with decubitus or inspiratory/expiratory films. However, it is performed with continuous and real-time imaging of chest by radiologist and is therefore generally available only during hours that a radiologist is immediately available. An additional drawback to fluoroscopy is the additional radiation typically administered during the test compared with plain films.

Intussiception presentation

1) Paroxysms of severe abdominal pain with inconsolable crying 2) Passage of "currant jelly" stool containing blood and mucus 3) Palpation of a "sausage-shaped" mass in the right abdomen A minority of patients present with classic triad of findings. Diagnosis requires a high index of suspicion. Additional signs and symptoms may include vomiting (bilious or non-bilious), lethargy and a toxic appearance, with or without signs of pain.

Anti seizure meds (4)

1) Phenobarbital: simple febrile seizures when given regularly and drug levels remain in therapeutic range. 2) Primidone: effective in preventing recurrence of simple febrile seizures but also has a high side effect profile. 3) Valproic acid: prevents recurrence of simple febrile seizures but carries with it dreaded side effect of hepatotoxicity. 4) Diazepam intermittent diazepam use (orally or rectally): if given at start of febrile illness, can be effective in preventing recurrent febrile seizures. NO 4) Carbamazepine: NOT effective in preventing febrile seizure recurrence. NO 5) Phenytoin not been shown effective in preventing febrile seizure recurrence.

Differential Diagnosis for Tachypnea in the Newborn

1) Respiratory distress syndrome (RDS): ** most common. deficiency of lung surfactant and delayed lung maturation. Can be as late as 37 weeks' gestation 2) Transient tachypnea of newborn (TTN): Result of delayed clearance of fluid from lungs following birth. More common in infants born to diabetic mothers and by c-section. Term infants. 3) Pneumothorax: collection of gas in pleural space with resultant collapse of lung tissue. Common RF: mechanical ventilation or underlying lung disease (especially meconium aspiration or severe infant RDS). Uncommon, more likely in premature infant with RDS 4) Hypoglycemia: Can be more pronounced in premature infants. Tachypnea is a non-specific response to this metabolic derangement 5) CHF 6) Neonatal sepsis: can present initially with tachypnea and progress to more severe illness rapidly. Often GBS. Associated with prolonged PROM. 7) Congenital diaphragmatic hernia: from a defect in the development of the diaphragm. Left side. 1 out of every 2,200-5,000 live births. Absent breath sounds or presence of bowel sounds on one side of the chest are important diagnostic clues. 8) Severe coarctation of aorta: if there is severe LV outflow tract obstruction 9) Meconium aspiration 10) Maternal drug exposure 11) Hypothermia. Premature more at risk.

2 immunizations to make sure a person with asthma gets

1) Seasonal influenza immunization: Individuals with asthma should receive a flu shot every year. 2) Varicella: Children on steroids (either inhaled or systemic) are at high risk for a severe primary varicella infection if they have not yet had chicken pox or have not been immunized. It is important to ensure that they have received both doses of the varicella vaccine.

Which conditions require an early referral to an ophthalmologist

1) Stevens Johnson Syndrome (SJS) to determine the degree of eye involvement and if treatment with topical steroids is needed. SJS is a mucocutaneous disorder defined by fever, severe stomatitis (inflammation of the mucous lining of any of the structures in the mouth), conjunctivitis, and a blistering rash. It is typically caused precipitated by medications or infections. 2) Juvenile idiopathic arthritis: can suffer from uveitis, which if left untreated, can lead to long-term problems such as cataracts, glaucoma, or blindness.

Common procedures for young children with sickle cell disease

1) Tonsillectomy: Waldeyer's ring hyperplasia is common in children with SCD. Tonsillectomy with adenoidectomy will improve obstructive apnea for most patients. 2) Cholecystectomy: Bilirubin gallstones occur frequently in all pts with hemolytic anemias---including SCD---result of increased release of hemoglobin during breakdown of abnormal RBCs. Although rare in first 5 years of life, an increasing # of children are found to have gallstones during adolescent ages. Although many children with SCD may have evidence of gallstones on screening ultrasounds, management is conservative and cholecystectomies are reserved for patients who are symptomatic. If sxs require it, cholecystectomy preferably is done as an elective procedure, with preoperative transfusions of packed red blood cells (pRBCs) given to reduce chances of acute chest syndrome or other complications following surgery due to time under anesthesia. Cholecystitis can be a serious infection to treat, so tx is warranted if there are any symptoms from the cholelithiasis.

Karyotypes for Down syndrome

1) Trisomy 21 (47, XY,+21 in this boy) (most common and most likely, regardless of mother's age); 2) unbalanced chromosome translocation resulting in extra chromosome 21 material 3) Mosaicism for a trisomy 21 cell line. likelihood of finding a translocation increases in infants born to younger mothers, but trisomy is still most likely, regardless of the parental age.

Screening of secondary HTN in children

1) Umbilical Arterial or Venous Access: Placement of umbilical arterial or venous line during the perinatal period may predispose to renal vascular disease. 2) Urinary Tract Infection Although less common in boys, UTIs in childhood are one of the leading causes of hypertension and renal insufficiency later in life. This is due to renal scarring following infection. 3) Catecholamine Excess Although some children with catecholamine excess, e.g., pheochromocytoma or neuroblastoma, may not have symptoms such as flushing or sweating or palpitations, a positive response to a screening question in a hypertensive child would merit urine catecholamine testing. 4) Family History of Renal Disease Ask about family history for hypertension and kidney disease. Inquiring whether a family member has needed dialysis is a good screening question for severe kidney disease. 5) Coarctation of the Aorta Some children with coarctation of the aorta may go undetected until presenting with hypertension at a school-age visit. On exam, pay special attention to the femoral pulses and consider documenting BP measurement in a lower extremity.

Routine Newborn Medications

1) Vitamin K: to prevent hemorrhagic disease of newborn (now also referred to as vitamin K deficiency bleeding). 2) Hep B vaccine: routine care of all medically stable newborns weighing > 2000 grams. Hepatitis B immunoglobulin (HBIG) is given only to newborns at risk for vertical transmission of hepatitis B virus. 3) Erythromycin (also tetracycline or silver nitrate): topical, to prevent gonococcal conjunctivitis.

Management DKA

1) Volume expansion (IVF NS bolus at 20mL/kg) 2) insulin drip (0.1 units/kg/hour) usually about 1 hour after starting fluids. 3) Maintenance fluids 4) Bicarbonate should NOT be given routinely because of well-described paradoxical CNS acidosis and hypokalemia from rapid correction of acidosis 5) Add K to IVF when serum level is known.

Newborn Resuscitation Step and Prevalence

1) Warm + dry infant, remove any wet linens immediately. Infants have a large surface area relative to their body weight and can thus experience significant hypothermia from evaporation. 2) Stimulate infant to elicit a vigorous cry: Helps clear lungs and mobilize secretions. 3) Suction amniotic fluid from infant's nose and mouth: helps clear the upper airway. 4) Initiate further resuscitation if required. Ex: blow-by oxygen, positive pressure (bag-valve mask) ventilation with oxygen, chest compressions, and medications. While approximately 10% of newborns require some assistance to initiate breathing, fewer than 1% require extensive rescuscitation.

Migraine atypical syndromes (3)

1) cyclical vomiting 2) abdominal migraines 3) benign paroxysmal vertigo These atypical "migraine variants" are seen exclusively in pediatric age group.

Signs and Symptoms of Bacterial Sinusitis

1) persistence of sxs without improvement, as viral URI symptoms tend to improve gradually over course of a week or so. 2) In younger children, a diagnosis of sinusitis should be made based on: -Persistence of bl nasal discharge of any quality or daytime cough, or both, lasting >10 days w/o improvement OR - Worsening after initial improvement ("double-sickening") OR - High fever >39and purulent nasal discharge for >3 days.

Viral vs bacterial pneumonia lab findings

1) viral pneumonia: - peripheral WBC counts t: normal or only slightly elevated. - Viral antigen testing of respiratory secretions may be helpful in making diagnosis but is usually not necessary. 2)bacterial pneumonia: - peripheral WBC counts usually elevated with neutrophilic predominance.

Diagnostic criteria for DKA

1. A random blood glucose of > 200 mg/dL (> 11.1 mmol/L) 2. A venous pH < 7.3 or serum bicarbonate < 15 mEq/L (< 15 mmol/L), and 3. Moderate or large ketonuria or ketonemia.

Diabetes dx

1. symptoms of diabetes (polyuria, polydipsia, and unexplained weight loss) + random plasma glucose concentration > 200 mg/dL (11.1 mmol/L). 2. fasting (for at least 8 hours) blood glucose > 126 mg/dL (7.0 mmol/L). 3. 2-hour postload glucose of > 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test. 4. ONLY ADULT: HbA1c values in dx of diabetes. A HbA1c ≥ 6.5%.

Jaundice Associated with Breastfeeding

1. Breastfeeding jaundice - in first week of life - when milk supply is relatively or absolutely low, resulting - low intake -> decreased GI motility -> retention of meconium. -> β-glucuronidase in meconium deconjugates bilirubin and unconjugated bilirubin is reabsorbed via enterohepatic circulation, causing an elevation of serum levels. - Breast milk production typically increases greatly once "let-down" occurs. 2. Breast-milk jaundice - in first 4 to 7 days of life but may not peak until about 10 to 14 days. - cause not completely understood - theory: β-glucuronidase present in breast milk deconjugates bilirubin in intestinal tract-> unconjugated bilirubin is then reabsorbed via enterohepatic circulation. - can persist for up to 12 weeks, but total bilirubin concentration rarely, if ever, reaches concerning levels.

Dx PID

1. Cervical motion tenderness 2. Abdominal pain 3. Cervical discharge Laboratory tests: 1. Culture for bacteria 2. Molecular diagnostic tests (e.g., NAAT) on urine or cervical discharge for Chlamydia and N. gonorrhea. (most practitioners no longer obtain a gram stain.)

FTT causes

1. Chronic diarrhea or vomiting 2. Congestive heart failure (CHF):Difficulty feeding and respiratory distress would commonly be described. 3. Formula allergy: True milk-protein allergy is difficult to diagnose, but typically causes intestinal blood loss (may be gross or occult); These children may also have fussiness, particularly after feeds and vomiting. 4. Improperly prepared formula 5. Inadequate formula volume 6. Malabsorption (esp with loose stools) 7. Parental neglect 8. Severe gastroesophageal reflux 9. Hypothyroidism: comes with constipation 10. Gastroenteritis: associated with both vomiting and diarrhea and may also be associated with fever and/or bloody stools.

Most common causes of AMS in teenager (3)

1. Conditions that lead to acidosis and/or shock: Sepsis, Diabetic ketoacidosis (DKA) 2. Ingestion 3. A number of primary CNS problems

Tx of persistent otitis media with effusion

1. Conservative Management - if have it for 3 months with normal speech and language and no other risk factors for hearing loss: hearing assessment. - If assessment normal and no risk factors ( developmental delay, learning problems, Down syndrome, etc.), child can f/u at 3- to 6-month intervals until effusion resolves or child develops a hearing deficit, language delay, or structural abnormality of tympanic membrane or middle ear. 2) Counseling and controlling environmental factors 3) Myringotomy and Tube Placement - Bilateral myringotomy with tube placement in a child with chronic OME AND bilateral hearing loss.

Differential diagnosis of vomiting and AMS

1. DKA: Vomiting (precipitated by acidosis) + increased RR and vague/diffuse abdominal pain, significant dehydration due to vomiting and osmotic diuresis. Tachypnea. Rule out concurrent cerebral edema if AMS 2. Toxic ingestion: get vomiting, altered mental status, and obtundation. Dehydration possible depending on the extent of vomiting and degree to which any change in mental status impairs oral intake. Aspirin overdose may present with tachypnea.Abdominal pain may be seen in toxic ingestions—in an overdose of iron, for example. 3. GI obstruction: Vomiting, sometimes bilious. Dehydration. Abdominal pain is a prominent feature. AMS unlikely. 4. Increased ICP: often presents with vomiting. Tumor might cause a central DI. A patient with increased ICP may exhibit an altered level of consciousness, often preceded/accompanied by headache. 5. Gastroenteritis: most common cause of vomiting; viral or bacterial. Get fever, colicky abdominal pain, and diarrhea. Dehydration is common. 6. Appendicitis 7. Bacterial pneumonia: should be investigated in any child presenting with abdominal pain ( inflammation of pleura).If patient becomes septic, can see a diminished level of consciousness. Signs of dehydration = mild. 8. Pyelonephritis:Vomiting may be seen in pyelonephritis and may lead to dehydration. They have urinary frequency NOT polyuria.

staging of neuroblastoma

1. tumor to area of origin, 2. tumor beyond area, maybe ipsilateral LN 3. beyond midline or regional LN involvment. 4. Disseminated tumor to distant LN, bone, bm, liver. 4S. Localized primary tumore as in stage 1 or 2 with dissemination limited to liver, skin, bone marrow

Questions to ask yourself to rule out malignant murmur:

1. Is the child otherwise well? 2. Is the precordial activity normal? 3. Is the second heart sound normally split? 4. Is the murmur less than or equal to grade II/VI? 5. Is the oxygen saturation normal? If the answer to any of these questions is "no," the murmur should not be considered innocent.

Complication PID

1. Most worrisome long-term morbidity is increased rates of infertility. 2.Sepsis 3. Tubo-ovarian abscess 4. Other intra-abdominal abscesses.

Metabolic diseases causing ataxia (2)

1. maple syrup urine disease 2. pyruvate decarboxylase deficiency.

Five Latino normative cultural values and consequences

1. Simpatía (kindness): politeness and pleasantness in face of stress; avoidance of hostile confrontation; includes assumption that physicians have a positive regard for patients. 2. Personalismo (formal friendliness): expectation of developing a warm, personal relationship with a clinician. Consider decreasing the physical distance during interactions with patients, providing contact information such as a beeper number, and showing an interest in patients' lives at each visit. 3. Respeto (respect): deferential behavior based on a position of authority, age, gender, social position, and economic status. Health care providers are viewed as authority figures deserving of respeto. Patients expect reciprocal respeto from provider, especially if provider is younger than the patient. 4. Familismo: collective loyalty to extended family that outweighs needs of individual. Extended families, not individuals, make decisions on important issues such as health care. When possible, provide ample time and opportunity for the extended family to gather to discuss important medical decisions. 5. Fatalismo (fatalism): belief that an individual can do little to alter fate. •Can lead to less preventive screening and avoidance of effective therapies.

Basic steps of fluid management

1. bolus fluids to restore intravascular volume - 10-20 mL/kg bolus of 0.9% saline (isotonic or "normal" saline). The gen rec for patients who are not in DKA or renal failure is to provide serial boluses until the patient urinates. However, patients in DKA typically start urinating very shortly after providing fluid boluses due to osmotic diuresis. Therefore, patients in DKA should be monitored for improvement of their vital signs (normalized heart rate and blood pressure) and mental status. 2. Correct dehydration - amount of fluid required to replace patient's deficit is dictated by your assessment of the degree of dehydration (3-5%, 6-10% or 11-15%). The composition of fluid (0.3% saline, 0.45% saline, 0.9% saline, etc.) and rate of infusion is dictated by the serum sodium concentration/osmolarity. In hyponatremic dehydration a sodium deficit is calculated, and in hypernatremic dehydration a free water deficit is calculated. 3. Provide maintenance fluids - Maintenance fluids replace daily insensible losses (perspiration and respiration) and normal urine output (approximately 2.0 mL/kg/hr for children < 15 kg and 1.0 mL/kg/hr for children > 15 kg and adults). Insensible losses account for approximately 40% of daily maintenance needs, while normal urine output accounts for about 60%. In general, 0.25% saline (1/4 normal saline) or 0.45% saline (1/2 normal saline) with 5-10% dextrose is used to provide maintenance fluids. 4. Replace ongoing losses - amount and type of replacement fluid is determined by thesource of the losses. For example, in gastroenteritis with ongoing diarrhea, stool output that exceeds 1.0 g/kg/hr should be replaced every 4 to 6 hours with 0.45% saline (1/2 normal saline). Additional examples of ongoing losses are emesis, NGT output, increased insensible losses due to fever, and tachypnea.

Absence of red reflex differential

1. cataracts 2. glaucoma 3. rb 4. chorioretinitis

how many cals do 9 month old infants need?

100kcal/kg/day; usually get 75% of nutrition; continue to introduce foods one at a time so that allergies can be identified

When do kids start to imitate?

18 months

Presence of handedness should not occur before:

18-24 months

microcytic anemia

Iron deficiency Thalassemia Chronic inflammation Lead poisoning Sideroblastic anemia

Anatomy of ventricular septum and VSD

3 distinct anatomic structures: - inlet septum (embryologic endocardial cushion) - outlet septum (embryologic conotruncus) - muscular septum (embryologic trabecular septum) - "fusion" point of these structures is membranous septum. VSDs occur due to either a lack of tissue (such as an endocardial cushion defect resulting in an inlet VSD) or a lack of fusion (lack of fusion of the embryologic components at the membranous septum, resulting in a "peri" membranous defect).

At what age do kids present with pyloric stenosis?

3weeks

Minimum systolic in kids <10yrs

70 + double your age

A 3-month-old male presents to the ED with a fever that started the previous day. Mother reports that he was fussy and had decreased oral intake. He had had five fewer diaper changes than usual. He had no vomiting, diarrhea, or respiratory difficulty. On physical exam his temperature is 101.6 F, pulse 110 bpm, RR 24 bpm, and BP 95/67 mmHg. The baby seems irritable and is not consolable by the parent. HEENT exam was significant for dry mucous membranes. Other than his irritability, the rest of the physical exam was unremarkable. CBC showed WBC 3.5, but was otherwise normal. BMP was within normal limits. Urinalysis showed positive leukocyte esterase, positive nitrite, and WBCs > 10/hpf. An LP was performed, and urine and CSF culture results are pending. The patient is placed on IV fluids and is started on cefotaxime. What is the next best step in evaluation? A Renal bladder ultrasound B Kidney-ureter-bladder (KUB) x-ray C Intravenous pyelogram D VCUG E Oral ampicillin

A has been selected by the expert. A. This infant has a fever without other respiratory symptoms. Meningitis and UTI must be considered in patients with fever. The only way to rule out meningitis is by lumbar puncture. This patient has a low WBC, suspicious for sepsis, and a UA that is highly suggestive of UTI. Empiric therapy should be started to cover common organisms including E.coli, P. mirabilis, and Klebsiella. Cefotaxime is reasonable empiric therapy. Renal ultrasound is recommended for all infants with pyelonephritis to assess for renal structural abnormalities or signs of obstructive uropathy (hydronephrosis). B. KUB is not recommended for UTI. C. Intravenous pyelogram would expose the patient to radiation and would not be recommended to screen for renal abnormalities. D. VCUG screening is recommended only for recurrent UTI or when there is abnormal renal ultrasound. E. The patient is already on parenteral antibiotics, so oral antibiotics would not be necessary. Also, ampicillin would not provide empiric coverage.

A mother brings her 20-day-old male infant to your clinic for the child's first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been vomiting 2 to 3 times per day, and the mother reports that her son seems fussier than her friends' infants. On exam, you note an eczematous rash and a musty odor to the infant's skin and urine. Which enzyme deficiency would you expect the infant to display? Please select one answer. A Phenylalanine hydroxylase B Cystathionine synthase C Sphingomyelinase D Alpha-L-iduronidase E Glucose-6-phosphatase

A has been selected by the expert. Likely has phenylketonuria (PKU), autosomal recessive disorder of amino acid metabolism caused by a deficiency in the enzyme phenylalanine hydroxylase. Affected infants are normally detected by newborn screening, but can present with vomiting, hypotonia, musty odor, developmental delay, and decreased pigmentation of the hair and eyes. The best developmental outcomes occur if a phenylalanine-restricted diet is initiated in infancy. B. A defect in cystathionine synthase occurs in homocystinuria, a disorder of amino acid metabolism. Homocystinuria is inherited in an autosomal recessive pattern. Individuals display Marfanoid body habitus, a hypercoaguable state, and possible developmental delay. The condition can be diagnosed by testing for increased methionine in a patient's urine or blood. C. A defect in sphingomyelinase occurs in Niemann-Pick disease, a lysosomal storage disease. Children present by six months of age with hepatomegaly, ataxia, seizures, and progressive neurologic degeneration. Fundoscopic exam reveals a "cherry-red" macula. D. A defect in alpha-L-iduronidase occurs in Hurler syndrome, a type of autosomal recessive lysosomal storage disease. Children typically do not display symptoms until one year of age. Symptoms include hepatosplenomegaly, coarse facial features, frontal bossing, corneal clouding, and developmental delay. Affected individuals typically do not live past fifteen years old. E. A defect in glucose-6-phosphatase occurs in Von Gierke's disease, a glycogen storage disease. Von Gierke's disease is inherited in an autosomal recessive pattern. Individuals present with hypoglycemia, hepatomegaly, and metabolic acidosis.

A 19-year-old female in her 38th week of pregnancy goes into active labor. Shortly after birth her baby is noted to have a high-pitched cry, tremulousness, hypertonicity, and feeding difficulties. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. What is the drug the baby's mother likely used during her pregnancy? A Heroin B Alcohol C Marijuana D Cocaine E Tobacco

A has been selected by the expert. Opiate use during pregnancy may result in several different symptoms, including CNS findings (irritability, hyperactivity, hypertonicity, incessant high-pitched cry, tremors, seizures), GI symptoms (vomiting, diarrhea, weight loss, poor feeding, incessant hunger, excessive salivation), and respiratory findings (including nasal stuffiness, sneezing, and yawning). B. Alcohol is incorrect. Fetal alcohol syndrome has a distinct pattern of facial abnormalities, growth deficiency, and CNS dysfunction. These infants may also exhibit other neurobehavioral deficits such as poor motor skills and hand-eye coordination and learning problems, such as difficulties with memory, attention, and judgment. C. Marijuana is incorrect. There is limited evidence for a withdrawal syndrome associated with marijuana use. D. Cocaine use during pregnancy is not typically associated with withdrawal symptoms. Linked to subtle deficits appreciated later in childhood, including deficits in cognitive performance, information processing, and attention to tasks. E. Tobacco is incorrect. Smoking is not associated with withdrawal syndrome described above. Smoking has been linked in a dose-dependent manner with lower weight newborns at birth. There is a two-fold increase in low birth weight even in light smokers (< 10 cigarettes per day). Smoking during pregnancy also has been associated with subtle neurodevelopmental deficits in some exposed children.

An 8-year-old healthy obese African American male with no past medical history is found to have a blood pressure of 125/90 mmHg on all four extremities on routine evaluation during an office visit for well-child care. Review of symptoms is negative. A physical exam and screening bloodwork are performed. Both are normal, with the exception of his blood pressure and obesity. What is the most likely diagnosis? A Primary hypertension B Renal artery stenosis C Coarctation of the aorta D Pheochromocytoma E Hyperthyroidism

A has been selected by the expert. The sole physical finding is hypertension. Given the mild hypertension and the patient's age, symptoms are unlikely to be present. Other etiologies should be ruled out, but review of symptoms, physical examination, and laboratory studies do not suggest other etiologies. B. Patients with renal artery stenosis are largely asymptomatic, but as the kidney function deteriorates, they may experience edema and dyspnea. On physical examination, patients will have hypertension (as a consequence of elevated angiotensin II and aldosterone) and possibly abdominal bruits. For laboratory studies, the patient will have elevated serum angiotensin II and serum aldosterone, as the kidneys attempt to compensate for a perceived decrease in glomerular filtration rate. C. Assuming sufficient severity of the coarctation, symptoms include chest pain, cold lower extremities, dizziness, syncope, exercise intolerance, failure to thrive, poor growth, headache, and dyspnea, among others. Distal to the coarctation, pulses will be diminished. Blood pressure will be lower in the lower extremities compared to the upper extremities. Murmurs may also be heart on auscultation. Coarctation of the aorta may also be associated with other congenital heart defects (bicuspid aortic valve in 50% of patients) and chromosomal abnormalities (Turner syndrome). D. Symptoms include headache, diaphoresis, palpitations, tremor, nausea, weakness, anxiety, nervousness, irritability, and weight loss, among other symptoms. On physical examination, patients typically present with tachycardia and severely elevated blood pressure. For laboratory studies, the patient will have elevated urinary VMA, urinary HVA, urinary metanephrines, and serum glucose. Pheochromocytoma may be associated with various syndromes, such as multiple endocrine neoplasia and Von Hippel-Lindau disease. E. Symptoms include heat intolerance, frequent bowel movements, increased appetite, diaphoresis, nervousness, restlessness, weight loss, tremor, hair loss, and palpitations, among others. On examination, patients typically present with tachycardia, hypertension, hyperreflexia, and goiter. The patient will have elevated T3, T4, and serum glucose, and TSH may be depressed or elevated depending on the etiology.

Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? A Wilms' tumor B Teratoma C Renal cell carcinoma D Hepatoblastoma

A has been selected by the expert. Wilms' tumor is commonly associated with Beckwith-Wiedemann syndrome, a genetic overgrowth syndrome. Other features that may be seen in children with this syndrome include omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features. B. Teratomas are congenital tumors that are present at birth. These benign tumors that are often identified incidentally, or may become symptomatic due to mass effect of the lesion within the abdominal cavity. The aggressiveness of the tumor depends on the degree of differentiation. C. Renal cell carcinomas are much more common in adulthood. Risk factors include cigarette smoking and obesity. D. While children with Beckwith-Wiedemann syndrome can have hepatoblastoma (in addition to other types of tumors), this is not the most common tumor in this genetic condition. Note that hepatoblastoma may also be associated with familial adenomatous polyposis.

Differential diagnosis for AMS (AEIOU TIPS)

A, E, I, O, U + TIPS : - Alcohol, ingested toxins - Epilepsy, encephalitis, endocrine, electrolytes - Infection, insulin - Overdose, opiates, oxygen deprived - Uremia (renal failure) - Trauma, temperature - Insulin, infection - Psychosis - Stroke, shock, space occupying lesions Also: hypoxemia

An 8-year-old boy presents with tea-colored urine, oliguria, joint pain, hypertension, and generalized edema. One month ago, he presented with fever and sore throat, headache, abdominal pain, strawberry tongue, papular sandpaper rash. At that time, he did not have runny nose, congestion or cough. He was treated with appropriate antibiotics for his symptoms and made a full recovery. Which of the following diagnostic findings supports his new symptoms? A ANA positive B Low anti-streptolysin O titer C Normal C3 complement D Low C3 complement E Gram negative organisms on urine culture

A. ANA is used to screen for lupus glomerulonephritis and will be elevated in lupus, but not in post-streptococcal glomerulonephritis (PSGN). B. PSGN is associated with high ASO titers, not low titers. C. PSGN is associated with low C3. Normal C3 is found in IgA nephropathy. ****D. C3 decreased in PSGN. This value will return to normal 6-8 eight weeks after presentation of PSGN symptoms. Although this patient was treated appropriately for his strep throat, treatment does not prevent PSGN. However, timely and appropriate treatment of strep throat will prevent development of rheumatic fever. More details for those really curious: C3 plays a role in bacterial killing. A low C3 > less bacterial killing > more prone to infection. A low C3 is also associated with increased risk for autoimmune diseases. E. This is incorrect. Gram negative organisms on urine culture is associated with UTI, not PSGN.

A 16-year old female presents to the ED with abdominal pain. Upon questioning, patient notes that pain is pretty consistently in the RLQ without radiation. She denies dysuria, hematuria, or blood in the stool. She has a history of multiple sexual partners and inconsistent condom use. She does not use any other contraceptive measures. She believes her last menstrual period was 3 weeks ago, but she is unsure. She has no history of abdominal or pelvic surgeries. Her temperature is 100.8 F, heart rate is 85 bpm, respiratory rate is 12 bpm, and blood pressure is 110/70 mmHg. Her abdominal exam is notable for involuntary guarding, tenderness to palpation in RLQ without rebound tenderness, and no CVA tenderness. Her pelvic exam is notable for cervical motion tenderness with some discharge. What is best NEXT step in management? A Abdominal CT B Pregnancy test C Pelvic ultrasound D Cervical cultures E Empiric antibiotics

A. Abdominal CT may be necessary as a part of the future workup if initial workup is negative. However, history and physical suggest pelvic inflammatory disease, and CT would not be a part of the initial workup. Importantly, given the history of multiple sexual partners, inconsistent birth control use, and questionable LMP, pregnancy is a possibility, and a CT would be harmful to the fetus. ****B. A pregnancy test is the best first step in management. Pregnancy is one of the indications for inpatient management of PID, so this is very important information when determining whether to admit patient from the ED or to provide outpatient tx. While cervical cultures and empiric antibiotics are obviously a must when you suspect PID, pregnancy test is the first step, and the best answer. C. Pelvic ultrasound is a useful technique to check for tubo-ovarian abscess or pregnancy (including ectopic), but a pregnancy test is still the best first choice. Also, pelvic ultrasound as a diagnostic tool is controversial, and often the diagnosis is made clinically. D. Cervical cultures are typically performed, looking specifically for N. gonorrhoeae or C. trachomatis, but a pregnancy test is still performed first. E. Physicians will often begin empiric antibiotic immediately based on this presentation, as it is classic for PID. However, they will always get a pregnancy test first to determine if admission for IV antibiotics is necessary rather than outpatient treatment.

A 5-year-old African-American male with sickle cell disease presents to clinic with a chief complaint of severe chest pain for the past day. His mother notes that he has been breathing quickly and that she measured his temperature this morning to be 100.5 F. Patient describes pain as an 8/10 on the faces scale. Patient is tachypneic on exam and has an oxygen saturation of 97% on room air. Chest exam reveals normal lung sounds bilaterally, and he has some reproducible tenderness over his chest wall. A chest x-ray is performed and demonstrates clear lung fields and a cardiac silhouette that is within normal limits. What is the most likely cause of the chest pain? A Acute chest syndrome B Rib infarction C Sepsis D CHF E Pneumothorax

A. Acute chest syndrome (ACS) is incorrect, because there is NORMAL oxygen saturation, and normal lung fields on radiological investigation. Lung markings on chest x-ray suggestive of ACS: pulmonary infiltrates, atelectasis, and effusion. Causes of ACS include infection, pulmonary fat embolism, or intrapulmonary sickling. Typical therapy may involve supplemental oxygen, pain management, hydration, antibiotics and possibly transfusion. ****B. Rib infarction is correct because of the chest pain in setting of a history of sickle cell disease with normal oxygen saturation and clear lung fields on chest x-ray. Osteomyelitis and painful vaso-occlusive crises represent most common reasons for admission for sickle cell disease patients. Rib infarction may lead to a picture similar to ACS as pain can lead to hypoventilation, which may result in atelectasis and characteristic radiographic findings of ACS. However, no radiographic findings are present in this patient. As a result, rib infarction is the most likely etiology. C. Sepsis would not typically present with isolated chest pain. Sepsis may often happen with sickle cell disease patients, given their susceptibility to infection. If cardiogenic shock follows, cardiomegaly may be appreciated. New infiltrates may occur if ARDS results secondarily from sepsis. However neither cardiomegaly nor new infiltrates were appreciated in this patient. While neither is required for the diagnosis of sepsis, the presence of fever may be the only indication of sepsis in a child with sickle cell disease. As a result, while less likely, sepsis is critical to include in the differential for this patient and to treat empirically until ruled out. D. CHF is incorrect because, like sepsis, it would not typically cause chest pain on its own. Additionally, abnormal lung markings and/or cardiomegaly would be expected in a patient with CHF. Neither is present in the patient in this vignette. E. Pneumothorax is incorrect because, other than rate, no abnormalities were noted on respiratory examination, and there were no supporting findings on chest x-ray. While a pneumothorax may cause chest pain, typically described as sharp and worsening with inspiration, this child's physical exam and radiographic findings make this option much less likely.

An 8-year-old girl comes to the clinic with a chief complaint of a "cold" for the past two weeks. On further questioning, she developed a fever of 38.7°C, purulent nasal secretions, malodorous breath, and a nocturnal cough three days ago. Examination of the nose reveals pus bilaterally in the middle meatus, and tenderness over the mid-face. Which of the following is the most likely diagnosis? A Allergies B Maxillary sinusitis C Asthma D Frontal sinusitis E Middle ear infection

A. Allergies are a very common diagnosis in pediatrics, and nocturnal cough is a frequently associated symptom. However, allergies usually cause clear, thin nasal secretions and are usually not associated with fever and malodorous breath. Other physical exam findings associated with allergies may include allergic shiners, cobblestoning of posterior pharynx, and edematous turbinates. ****B. The maxillary and ethmoid sinuses are large enough to harbor infection in infancy. Sphenoid sinuses do not become large enough until the 3rd-5th year of life, and frontal sinuses are rarely large enough until 6-10th year of life. Pus draining from the middle meatus is suggestive of either maxillary, frontal, or anterior ethmoid sinusitis. D. Distinguishing between the different locations of sinusitis can be clinically challenging, especially in a 9-year-old patient who likely has mature sinuses. However, frontal sinusitis is characterized by pain over frontal bone and perhaps facial swelling in an older child or adolescent. It is less likely to cause the symptoms described here.

A 2-month-old male is brought to the ED after his mother found him in his crib not breathing. She says he had no color and was still when she found him, but quickly regained his color. While you are examining him he starts having a tonic-clonic seizure and subsequently is found to have a temperature of 96 F, HR 200 bpm, and RR 18 bpm. On exam he cries intermittently, does not track you with his eyes, has a tense, full fontanelle, and decreased tone throughout. You also notice a healing bruise on his left arm. After assessing circulation, airway, and breathing you obtain IV access. What is the next step in your diagnostic workup? A Skeletal survey B Lumbar puncture C Head CT D Head MRI E Social work consult

A. Although in cases of child abuse a skeletal survey should be included in the diagnostic work up, it is not the initial test of choice. B. Meningitis is on differential; however, this child is afebrile and consolable making this diagnosis less likely. Other causes of AMS and seizures should be ruled out first. ****C. This choice is correct because head CT is highly sensitive for an intracranial bleed, such as a subdural hematoma, can be quickly carried out in the emergency setting, and may require urgent intervention. D. MRI is less sensitive for an early bleed than CT, and would require sedation. However, MRI can be used as a confirmatory study after the child is stabilized. E. This choice is incorrect because this infant is not stable. However, a consult would be appropriate after the infant is stabilized.

A 3-year-old male presents to clinic with annular, well-circumscribed, scaly plaque with a raised erythematous border and central hypopigmentation on left thigh. The mother reports that the lesion is highly pruritic and that the patient has been exposed to other children with a similar rash at day care. Upon further examination, a similar lesion with boggy borders is also found on the posterior aspect of his scalp. Which of the following is the most appropriate treatment for this child's problem? A Topical clotrimazole B Hydrocortisone 1% cream C Oral prednisone D Oral griseofulvin E Selenium sulfide shampoo

A. Although topical antifungal therapy would be appropriate for lesion on the leg (tinea corporis), involvement of scalp (tinea capitis) necessitates systemic antifungals. B. Steroid therapy is contraindicated in treatment of fungal infections. Treatment with hydrocortisone cream will worsen the fungal infection. ***D. This choice is correct. Topical antifungals are not usually successful in treating tinea capitis, because the infected hair follicles are deep within the scalp. E. Selenium sulfide shampoo may decrease the likelihood of transmission of the infection to others by decreasing the number of spores shed, but does not treat the primary infection.

A 16-year-old male presents to your office requesting clearance to play football. You begin by taking his medical history. He says that he feels very well, but admits that he recently experienced one episode of syncope that occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while playing basketball. Physical examination reveals no abnormalities. What is the next best step in management? A ECG now, and if normal, reassurance B Medically clear him to play C Stress test D ECG and referral to cardiology E Observe and follow up in 6 months

A. An ECG is indicated in all cases of syncope. Neurocardiogenic syncope, also known as vasovagal syncope, occurs when the brain is not being adequately perfused. Predisposing factors may include dehydration, hypovolemia, and standing up too quickly. It is not usually dangerous, and in these cases an ECG would be an appropriate first step. However, in cases of atypical syncope, as above, in which syncope occurs with exertion, and ECG would not be a sufficient work up. B. All medical issues must be resolved prior to clearing a patient to participate in a sport. Syncope with exertion, during exercise, is very concerning, and this patient should be worked up appropriately prior to clearance. C. A stress test is appropriate for evaluating chest pain, particularly in those at risk for atherosclerosis. However, in a patient with known syncope with exertion, a stress test might actually be dangerous. In addition, it only considers vessel disease as a source of pain, and does not take into account structural issues like an outlet obstruction. D. Referral to cardiology is the absolute next best step! The combination of syncope with exertion and a family history of a young death is concerning for something like hypertrophic cardiomyopathy. Don't be fooled about heat stroke. That is a positive family history for sudden death in a young person. This patient must be evaluated by cardiology, even if you don't hear a cardiac murmur! E. Observation is not appropriate here. As mentioned above, the syncopal event and positive family history are concerning. It would be inappropriate to just observe if this patient has hypertrophic cardiomyopathy, a very significant risk factor for sudden death. Cardiology consult is the only appropriate option here.

Claire is a 16-year-old female who presents for birth control management. Her review of symptoms is unremarkable except for chest pain. When you ask her more questions, she reveals the pains are intermittent, on and off for the past couple months. It is not associated with exertion, sharp, and well localized at the left sternal border. It is very brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in. She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and physical exam are normal. Which is the next best step in management? A ECG B Reassurance C Referral to a cardiologist D Fast ultrasound of pericardial window E Chest x-ray

A. An ECG would be next if you suspected a cardiac abnormality. This would be more likely if the patient described something more like angina, a crushing chest pain or pressure, for longer periods of time rather than a few seconds, and aggravated by exercise. ***B. Based on the history, and assuming your physical exam is unremarkable, this sounds most suggestive of precordial catch syndrome, the most common cause of chest pain in an adolescent. No further workup is needed. C. Associated symptoms of syncope or palpitations would suggest a more severe cardiac abnormality and would prompt a referral to a cardiologist. The vignette states the rest of the ROS is negative and this would not warrant further evaluation now by a cardiologist. D. This would be the management if you suspected pericarditis or a pericardial effusion, but she denies recent URI or viral infection, and your PE is not notable for a pericardial friction rub suggestive of pericarditis. Her vitals are also stable and you might expect fever in pericarditis. E. A chest x-ray would be indicated if you suspected pneumonia that potentially might present with chest pain. However, the vignette didn't mention anything about cough and the patient is afebrile, making this less likely.

Johnny is a 25-month-old male who presents to the ED with a 2-day history of vomiting and diarrhea. Dad relays a history of abrupt onset of vomiting that started yesterday around 1 pm. Johnny has had 6 episodes of emesis since yesterday and 3 episodes of diarrhea. The emesis is non-bilious and the diarrhea is described as watery with specks of blood throughout the diarrhea. There are no sick contacts in the home. Vital signs: T 37.1, P 102, R 20, BP 90/60. Physical examination is normal and Johnny has still been tolerating some PO feeds without instant vomiting. What is the most immediate intervention for this patient? A IV bolus with D5W B IV bolus with 0.9% saline C CT scan and surgical consult D random glucose test E no immediate intervention is necessary

A. An IV bolus with D5W is indicated in cases of confirmed hypoglycemia and is used for maintenance fluids. B. With his normal vitals and no obvious signs of dehydration, an IV bolus of 0.9% saline is not indicated in this patient. If there was evidence of dehydration on physical exam or with vitals, then IV fluids would be necessary. C. This vignette does not seem like a surgical case. Physical examination was normal, which makes abdominal pathology less likely. While appendicitis might be in the differential diagnosis, other diagnoses are more likely, making the excessive radiation exposure from a CT scan not necessary. D. With cases of dehydration one must always think about abnormalities in blood glucose levels. ****E. At this point the patient is most likely suffering from a case of viral gastroenteritis. Because he is still tolerating some PO feeds, has no obvious signs of dehydration, and has normal vital signs, there is no need for aggressive IV fluid administration or diagnostic work up. Strict return precautions should be given and it should be advised that Johnny maintains fluids as much as possible.

A 2-year-old female is brought to the ED by her mother because of increasingly frequent abdominal pain. She has been experiencing this pain on and off for the past year, along with increasing abdominal distention, vomiting, and diarrhea. You chart her height and weight, and find that she is below the 5th percentile for both. IgA tissue transglutaminase (TTG) antibody returns positive. What is the best treatment for this patient? A Antibiotic treatment B Gluten-free diet C Corticosteroids D Pain management E Metronidazole

A. Antibiotics would be tx for some types of bacterial gastroenteritis. The chronic nature of this patient's abdominal pain strongly points away from a diagnosis of bacterial gastroenteritis, which would more likely be an acute disease. Falling off the growth curve also suggests a process that is more chronic than you would expect from bacterial gastroenteritis. Bacterial gastroenteritis typically presents with bloody diarrhea, with or without abdominal pain, and is associated with fecal leukocytes on Wright stain. ***B. A gluten-free diet is the best way to manage celiac disease. Celiac disease can present with chronic abdominal pain, vomiting, abdominal distention, and diarrhea. Growth failure can result from malabsorption or anorexia. Anemia may also result from occult GI bleeding, although frank blood in the stool is rare. The IgA tissue transglutaminase antibody titer is a very sensitive and specific test for this disease. C. Corticosteroids may be used to treat a flare of inflammatory bowel disease (IBD). Inflammatory bowel disease can present with mild/subacute or severe/acute abdominal pain, along with diarrhea (often bloody). Falling off growth curve is also common in patients with IBD. The positive IgA tissue transglutaminase antibody, however, suggests that a diagnosis of celiac is more likely in this patient. D. Pain management alone is not sufficient for a patient with abdominal pain if there is no diagnosis. This may be appropriate in patients with Henoch-Schonlein purpura (HSP), if they have joint and abdominal pains. The abdominal pain experienced by patients with HSP is usually acute in onset and preceded by characteristic palpable purpuric rash. E. Metronidazole is treatment of choice for giardiasis. Infections with giardia may be acute or chronic, but do not usually lead to growth failure. This patient's clinical picture may fit with a giardia infection, except that the positive IgA TTG antibody titer suggests a diagnosis of celiac disease.

You are called to the delivery of an infant boy experiencing fetal distress. After a vaginal delivery with vacuum assist, the infant cries spontaneously but remains acrocyanotic, despite supplemental oxygen delivered by mask. The neonate is hypotonic and moves his extremities only in response to noxious stimuli. Physical exam reveals an open mouth with a protruding tongue, upslanting palpebral fissures, low-set ears, and a transverse crease across both palms. You immediately recognize this syndrome, and your attending asks you what is the most common cardiac defect in these patients? A Aortic insufficiency B Coarctation of the aorta C Endocardial cushion defects D Patent ductus arteriosus E Conduction pathway defects

A. Aortic insufficiency associated with Marfan syndrome. B. Coarctation of the aorta is seen in 35% of patients with Turner syndrome. ****C. Endocardial cushion defects. This patient has physical signs of Down syndrome. Approximately 50% of children with Down syndrome are born with endocardial cushion defects, such as VSD, ASD, or complete atrioventricular canal defect. D. PDA = prematurity, sepsis, metabolic acidosis, or pulmonary defects not associated with congenital syndromes. E. Conduction pathway defects are not characteristic of patients with Down syndrome but may be seen in infants born to mothers with lupus (heart block).

A 7-year-old boy is brought by ambulance to the ED with altered consciousness. The EMT said he found the boy in a pool of vomit. He is unable to answer questions coherently and he is alone. Physical exam findings indicate dry mucous membranes, tachypnea, tachycardia, and moaning on palpation of the abdomen. His physical exam is otherwise normal, including a normal blood pressure. What is the most likely cause of his condition? Single Choice Answer: A Appendicitis B DKA C Narcotic overdose D Non-accidental trauma E Sepsis

A. Appendicitis would rarely present with altered consciousness. The usual history with appendicitis is onset of periumbilical pain that persists over hours, migrating to the right lower quadrant. Vomiting could be present, and tachycardia may be present due to pain or dehydration, but altered mental status would be unusual. On physical exam, peritoneal signs may be present as well as psoas, obturator, or Rovsing's sign. B. CORRECT. DKA typically presents with altered mentation, vomiting, dehydration, and abdominal pain. The history will yield polydipsia and polyuria during the days preceding DKA. Metabolic acidosis causes tachypnea as the body tries to blow off CO2 through a compensatory respiratory alkalosis. C. Although he may have access to narcotics, his presentation does not fit well with this choice. Signs of narcotic overdose include pinpoint pupils, depressed respiratory rate, and altered consciousness. His tachypnea and lack of pinpoint pupils argue against this choice. D. Lack of fractures, bruises, or burns argues against this choice. Trauma resulting in increased intracranial pressure may result in hypertension, bradycardia, and disordered breathing. E. Sepsis can present with altered mental status. This child's presentation is less consistent with sepsis given that he doesn't have fever or other vital sign changes consistent with sepsis syndrome (temperature > 38.5°C or < 36°C, hypotension, along with warm, dry extremities

A previously healthy 4-year-old girl is brought to her pediatrician because her parents have noticed that she has been less active than usual for the past three weeks. Her father explains that it is difficult to get his daughter out of bed in the mornings and that she no longer plays outside with her older brother. Physical examination is notable for a temperature of 38.4 C, heart rate of 125 bpm, pallor, truncal bruising, and diffuse lymphadenopathy. The remainder of the exam, including a thorough neurologic assessment, is unremarkable. Which of the following is the most likely diagnosis? A Aseptic meningitis B Kawasaki disease C Non-accidental trauma D Acute lymphoblastic leukemia E Mononucleosis

A. Aseptic meningitis incorrect because cannot explain this child's pallor, bruising, or lymphadenopathy. While aseptic meningitis can present with lethargy and low-grade fevers, remainder of her symptoms are not consistent with meningitis. B. Kawasaki disease (KD) is incorrect because this child does not meet criteria for diagnosis. She has not had fevers for 5 days and has no other sxs consistent with KD. She has diffuse lymphadenopathy (not unilateral cervical LAN > 1.5cm in size) and also lacks bilateral nonsuppurative conjunctivitis, upper respiratory tract mucosal changes, extremity erythema or swelling, and polymorphous rash. ****D. Child presents with evidence of anemia (fatigue, tachycardia, pallor) and thrombocytopenia (unexplained bruising). Failure of two or more hematologic cell lines should always raise suspicion for malignant invasion of the marrow. Furthermore, the child's chief complaint, fatigue, is the most common presenting symptom of acute leukemia. Finally, the incidence of ALL peaks at age 4 years. E. Mononucleosis is incorrect because does not explain the apparent bone marrow failure evidenced by anemia (fatigue, tachycardia, pallor) and thrombocytopenia (bruising). This child's subacute presentation with marked fatigue, low-grade fevers, and lymphadenopathy is suggestive of mononucleosis, and this diagnosis should remain high on the differential. In a young child, however, one must first rule out acute leukemia.

A 15-year-old female comes to the clinic with a chief complaint of feeling tired for one month. She has also been complaining of frequent nosebleeds while at school and bruising easily. When further history is elicited, you find out that menarche was at the age of 9 and her periods have always been heavy and irregular. Her mother and grandmother also have histories of heavy periods and easy bruising. You suspect a bleeding disorder and send off some labs including a CBC, INR, PT, PTT, and a von Willebrand panel to confirm your diagnosis. Your suspicion was correct for the most common type of bleeding disorder. How is this bleeding disorder most commonly inherited? A Autosomal dominant inheritance B Autosomal recessive inheritance C X-linked recessive inheritance D Mitochondrial inheritance

A. Autosomal dominant (AD) inheritance is the correct choice. In AD disorders males and females are equally affected within each generation. These include conditions such as von Willebrand's disease, Marfan syndrome, neurofibromatosis, and Huntington's disease. B. Autosomal recessive (AR) is incorrect. In AR diseases female and male offspring of heterozygote carriers have a ¼ chance of being affected. These include Tay-Sachs disease and cystic fibrosis. C. X-linked recessive (XLR) is incorrect. In XLR disorders males are more commonly affected, while females are the carriers and pass the disorder on to their sons. Males cannot pass the disease on to other males. These include conditions such as Duchenne's muscular dystrophy, hemophilia, and Fragile X syndrome. D. Mitochondrial inheritance is incorrect. In mitochondrial disorders the disease is inherited only from the mother, and usually all children are affected. Affected males cannot pass the disorder on to their offspring. These include mitochondrial myopathies such as Leber's hereditary optic neuropathy and mitochondrial encephalopathy.

A young couple presents to the ED with their 2-month-old son complaining of excessive sleepiness and difficulty arousing him after his nap. Per the parents, the PMH and prenatal course are unremarkable, except that the patient has always been very fussy and would often cry despite being held and cradled. He is cared for during the day by his babysitter. Today he had been in his usual state of fussiness when babysitter arrived, and they returned to find him napping quietly in his cradle but could not arouse him from sleep when it came time for his feeds. He finally opened his eyes after several minutes of gentle nudging but seemed to quickly fall asleep again. On exam, patient is afebrile with poor tone and is only mildly responsive to painful stimuli. Eye exam shows dilated pupils and an ophthalmology consult reveals retinal hemorrhages. What is the most likely diagnosis? A Bacterial meningitis B Infant botulism C Intoxication D Closed head injury E Metabolic disorder

A. Bacterial meningitis is more common during first month of life than at any other point and is usually 2ary to GBS infection. While meningitis could account for some of sxs seen in our patient, such as lethargy and abnormal tone, fever is the most common symptom and is notably lacking in our patient. Retinal hemorrhages noted are also inconsistent with this dx and point more towards a closed head injury secondary to child abuse. B. Infant botulism results from ingestion of C. botulinum spores that germinate in the infant's GI tract leading to constipation, symmetric weakness, feeding difficulties, drooling, irritability and weak cry. It is commonly believed to be associated with ingestion of honey but can also be caused by ingestion of environmental dust containing C. botulinum spores. This dx, while on differential, is unlikely given the lack of symmetric weakness noted in the history and presence of other physical exam findings more consistent with child abuse. C. Intoxication caused by accidental ingestion of medications or toxins could result in sxs similar to those seen in our pts such as lethargy and poor tone but is UNLIKELY. The patient is also too young, at one month of age, to be able to accidentally obtain and ingest any medications or substances which may have fallen on the floor without an adult noticing—unlike children who are capable of crawling or walking—making this a less likely diagnosis. ****D. Closed head injuries and retinal hemorrhages in infants and children are secondary to violent shaking or throwing, resulting in tearing of the bridging vessels. Retinal hemorrhages, as seen in our patient, are pathognomonic for shaken baby syndrome. Other signs and symptoms include stiffness, constant crying, seizures, difficulty to arouse, decreased appetite and excessive sleeping. Victims often have no other signs of physical abuse (e.g., bruises).

A 3-week-old baby boy is brought to his pediatrician with a chief complaint of light tan-colored stools and worsening jaundice. His is exclusively breastfed and has 6-8 wet diapers per day. On exam, he appears to have scleral icterus and jaundice. Upon further workup, he is found to have an elevated direct bilirubin. What is his most likely diagnosis? A Biliary atresia B Breastfeeding jaundice C G6PD deficiency D Physiologic jaundice E Caput succedaneum

A. Biliary atresia can present anytime between birth and 8 weeks of age, but usually occurs after 2 weeks of age. Jaundice is usually first presenting finding, along with acholic stools, dark urine (from increased bilirubin excretion) and hepatosplenomegaly if the problem goes unrecognized. Laboratory values classically show an increased level of direct or conjugated bilirubin > 2 mg/dL. If biliary atresia is confirmed with further laboratory testing and imaging, surgical intervention must be pursued as soon as possible. B. Breastfeeding jaundice normally occurs within the first week of life, most often because of decreased intake leading to dehydration and increased enterohepatic circulation. This patient is exclusively breastfed, but his jaundice began at approximately day 16 of life. Also, breastfeeding jaundice increases unconjugated bilirubin levels, making this answer choice less likely. C. G6PD is an X-linked inherited disorder. The severity of this disorder is dependent upon the degree of deficiency of the enzyme, but may present with neonatal unconjugated hyperbilirubinemia. However, laboratory findings show hemolytic anemia in the symptomatic state. Hemolysis is usually elicited by drugs, most notably primaquine and dapsone, as well as fava beans. D. Physiologic jaundice peaks at 3-4 days of life and generally resolves within a day or two. This patient is well beyond that age, making this answer less likely. E. Caput succedaneum is caused by an increase in serum above the periosteum of an infant that crosses suture lines (as opposed to cephalohematoma which does not cross suture lines). The increased serum bilirubin does not usually lead to significant hyperbilirubinemia.

A 6-month-old baby boy is referred to your clinic because he has not been gaining weight appropriately. His mother denies any difficulty with feeding or reduced appetite, yet his weight has still dropped from 30th to 3rd percentile. Mother also complains that he has loose, malodorous stools. After a thorough workup, a diagnosis of cystic fibrosis (CF) is made. Which of the following is a TRUE statement regarding CF? A CF is an autosomal dominant disorder B CF is caused by a mutation in CFTR, resulting in defective salt balance C CF is a disease that exclusively involves the respiratory system D Gene therapy is now the primary source of CF therapy E It is important to provide calories at a lower level than recommended dietary allowance for a given age in order to prevent GI upset

A. CF is autosomal recessive, NOT dominant. Most people with CF do not have a positive family history. ****B. Correct. The mutation in CFTR gene results in defective salt balance. CF is caused by mutations in a single large gene on chromosome 7 that encodes the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Clinical disease requires disease-causing mutations in both copies of the CFTR gene. C. CF does involve the respiratory tract—leading to chronic cough and recurrent infections—but may also lead to pancreatic dysfunction, infertility, malnutrition, and more. D. Gene therapy is NOT a current treatment option for CF patients. However, there are studies right now that are investigating gene therapy. Current treatment includes a multidisciplinary approach, using treatments such as pancreatic enzyme and vitamin replacement, mucus clearing, possibly transplant, and more. E. It is necessary to provide calories at a HIGHER level than the recommended dietary allowance for age to maintain appropriate nutritional status, as CF patients usually have a malabsorption problem.

A 2-year-old male is brought into the ED by his mother because of vomiting and altered mental status. He has pinpoint pupils and seems to be drooling and sweating uncontrollably. His heart rate is 60 bpm, his respiratory rate is 45 bpm, and he seems to have difficulty breathing. Which ingestion is the most likely cause of his symptoms? A Organophosphates B Tricyclic antidepressant C Barbiturates D Codeine E Pseudoephedrine

A. CORRECT. Organophosphates cause cholinergic effects, such as miosis, sweating, lacrimation, salivation, urination, increased gastric mobility (vomiting, diarrhea), muscle twitching, bronchospasm, bradycardia, and seizures. A good mnemonic is SLUDGE (salivation, lacrimation, urination, defecation, GI mobility, emesis). B. Tricyclic antidepressants are part of the group of anticholinergics. Overdose can cause mydriasis, dry and red skin, fever, delirium, seizures, tachycardia, urinary retention, and ileus. C. Barbiturates are part of the group of sedative-hypnotics. Excessive ingestion presents as blurred vision, hypotension, apnea, bradycardia, hypothermia, sedation, delirium, and coma. D. Codeine and other opioids can cause miosis, respiratory depression, bradycardia, hypotension, hypothermia, and depressed mental status. E. Pseudoephedrine is a sympathomimetic, and overdose results in mydriasis, fever, diaphoresis, tachycardia, agitation, and seizures.

A previously healthy 14-year-old female presents to the ED with a one-day history of fever and altered mental status. Vital signs on presentation include: BP 120/70 mmHg, HR 145 bpm, RR 42 bpm, temp 39.7 C, oxygen sat 93%. Physical exam reveals nuchal rigidity, cool extremities, 1+ distal pulses, diffuse petechial rash, and capillary refill > 2 seconds. What is the important first step in management? A Place IV and start NS bolus B Order CBC, CMP, PT, and INR C Start empiric antibiotic therapy with IV ceftriaxone D Obtain a head CT E Order blood cultures

A. CORRECT. This patient is in septic shock due to meningococcal infection and should immediately be started on IV fluids in order to maintain perfusion to vital organ systems. Although this patient has a normal blood pressure, other vital signs and physical examination point to shock (HR and RR are both significantly elevated), which first and foremost requires fluid resuscitation. B. Although these labs will need to be obtained, patient must first be managed in order to ensure hemodynamic stability. Drawing blood for lab tests is not the first priority. C. Starting antibiotic therapy is the second step in management after hemodynamic stabilization. While antibiotics should be started as soon as possible, fluid resuscitation is still the classic "next best step" choice when presented with a patient in shock. D. A head CT is not indicated in the initial evaluation of a patient presenting in septic shock, regardless of the source of infection. If the patient were stable, then a head CT may be required to rule out any masses prior to LP. E. Blood cultures would be the step just prior to antibiotics, so as not to contaminate the results. However, cultures still come after fluid resuscitation when a patient is in shock.

A previously healthy and developmentally normal 16-month-old male comes to the urgent care clinic with his father with a chief complaint of his first reported seizure. The child was reported to have dropped to the floor with loss of consciousness and had sporadic twitchy movements of his legs and arms that lasted for five minutes. The child has had URI symptoms for the past two days, with a fever to 103 degrees F without any changes in mental status. Neither parent has a seizure disorder, but the child's mother reports having a single seizure as a young girl once after developing a high fever after a cold. What is the most likely diagnosis? A Epilepsy B Simple febrile seizure C Complex febrile seizure D Absence seizure E Cyanotic breath-holding spell

A. Choice A is incorrect because epilepsy is a recurring condition. Epilepsy seizures are usually classified as unprovoked. ****B. Febrile seizures are one of most common causes of seizures in children. Simple febrile seizures are more common than complex febrile seizures and are characterized by < 15 minutes duration, occurring only once in a 24-hour period, and are generalized (in this patient's case, generalized tonic-clonic). Febrile seizures are usually self-limited events triggered by an acute febrile illness. C. Choice C is incorrect because a complex febrile seizure is characterized by > 15 minute duration, occurring more than once during a 24-hour period, and being focal. D. Choice D is incorrect because absence seizures are generalized seizures, but children recover consciousness much more quickly, usually within 30 seconds, compared to tonic-clonic seizures, which take much longer. Absence seizures are most often seen in children starting from the age of 3 and are not associated with loss of tone. Potential causes include hyperventilation or photic stimulation. E. Choice E is incorrect. Breath-holding spells are most commonly seen in infants from 6 mos-6 years . In a cyanotic breath-holding spell infant becomes angry or upset and there is a period of crying, followed by breath-holding in a forced expiration state that may lead child to lose consciousness and become cyanotic. Child usually recovers soon thereafter with no residual side effects.

A 6-month-old male comes to clinic with a chief complaint of several weeks of vomiting after large feedings. The vomiting has become blood-streaked, which is when the mom became concerned and brought him in. The baby's PO intake has been down and he has been losing weight. Abdominal exam is normal, with no masses palpated. What is the most likely diagnosis? A Pyloric stenosis B Gastroenteritis C GERD D Volvulus E Intussusception

A. Choice A is incorrect because pyloric stenosis is characterized by a pattern of forceful, projectile, non-bilious vomiting, usually in younger infants. Infants are usually hungry and nurse avidly. An oval mass, 5-15 mm in longest dimension can be felt on deep palpation in the right upper abdomen, especially after vomiting. B. Choice B is incorrect. Large watery stools, which this patient did not have, are the hallmark of infectious gastroenteritis. Also, gastroenteritis is a more acute disease, while this patient is having more chronic symptoms. ***C. Choice C is correct because regurgitation/spitting up may be difficult to distinguish from true vomiting. Infants who reflux with overfeeding may sometimes have forceful vomiting. Severe esophagitis may result in blood-streaked emesis. Pain from reflux or esophagitis may lead to feeding aversion when gastroesophageal reflux is severe. D. Choice D is incorrect because in volvulus, blood may be seen in the stool but not typically in the vomitus. Bowel ischemia from volvulus can cause significant abdominal pain. E. Choice E is incorrect because in intussusception we might see the classic "currant jelly" stools. The abdominal exam in children with intussusception often shows the presence of a sausage-like mass due to the telescoped bowel.

A 6-year-old female comes to the clinic with a chief complaint of worsening right knee pain over the past month. On exam, you note generalized lymphadenopathy and splenomegaly. She coughs intermittently throughout the visit, and her mother explains that she is just getting over a cold. You note absence of tenderness, erythema, effusion or warmth over the hip, knee, or ankle joints. Her vitals are unremarkable except for a low-grade fever (100.8 F). Reviewing her chart, you note that she has lost 5 lbs since her visit 2 months ago. She sits with her right leg externally rotated but appears to be in pain despite trying several different positions, refusing to bear weight on that side. What is the most likely diagnosis? A Reactive arthritis B Leukemia C Osteomyelitis D Transient synovitis E Septic arthritis

A. Choice A is incorrect because reactive arthritis typically follows an infection outside the joint affecting the GU or GI tract (rather than upper respiratory tract), presenting two to four weeks following an infection. Children are commonly afebrile, and pain may involve multiple joints. ****B. Choice B is correct. Leukemia can present as bone pain due to replacement of bone marrow by leukemic cells. Patients may present with limp or refusal to walk. Leukemia is associated with systemic symptoms such as low-grade fever, chronic/insidious joint pain, generalized LAD, weight loss, and/or hepatosplenomegaly. C. Choice C is incorrect because osteomyelitis typically presents with point tenderness over bony joint and signs of joint inflammation. The pain is worse upon weight-bearing, and fever is seen in about 50% of cases. D. Choice D is incorrect because this patient is showing systemic symptoms such as weight loss, hepatosplenomegaly, and generalized LAD. Transient synovitis would be high on differential if this child were otherwise well-appearing with isolated involvement of the joint, most commonly the hip. Transient synovitis may follow an upper respiratory infection and usually resolves on its own within 3-7 days. E. Choice E is incorrect because the history and physical are more suggestive of leukemia; however, septic arthritis may present similarly. Erythema, warmth, and swelling of a deep joint may not be readily apparent on exam. While fever is strongly associated with septic arthritis, it would likely be higher (> 38.5 °C) and the patient would have a more acute presentation. A CBC with differential would be useful in this situation. An ultrasound of the joint would also be able to identify an effusion and/or guide joint aspiration if septic arthritis was suspected.

9-year-old male presents to the ED in an ambulance after he was found unconscious at a local playground. In the ED he is arousable but extremely obtunded. He is able to minimally verbalize that his head hurts and his stomach feels uncomfortable. He states the pain is constant and non-radiating. He vomits clear liquid twice over the course of 30 minutes. Vital signs are as follows: T 37.6 C, P 66 bpm, BP 155/80 mm Hg, RR 18 bpm. You further notice that his breathing is irregular with brief episodes of apnea. On physical exam you are unable to reproduce the abdominal pain and there is no rebound tenderness or guarding. The rest of the physical exam is unremarkable. What is the most likely diagnosis? A DKA B Appendicitis C Intracranial hemorrhage D Gastroenteritis E Small bowel obstruction

A. Choice A is incorrect, because in a patient with DKA one would expect increased adrenergic tone leading to tachycardia, not inappropriate slowing of the HR. Secondly, the patient's breathing pattern is more consistent with Cheyne-Stokes respirations, not Kussmaul breathing. Kussmaul breathing is typically characterized by deep breaths that may be rapid, normal or slow in rate without periods of apnea, often associated with metabolic acidosis. Lastly, one would expect signs or symptoms consistent with dehydration such as polyuria, polydipsia, decreased skin turgor, or skin tenting. However, the altered mental status, vomiting, headache, and abdominal pain could be seen in DKA. B. Choice B is incorrect because the lack of fever, inability to reproduce the abdominal pain in the RLQ, and the severely altered mental status argue against the diagnosis. In appendicitis, children will often complain of a migratory pain that beings around the periumbilical region and migrates to the RLQ. Patients often complain of rebound tenderness and demonstrate guarding as well. C. This is the correct choice. Increased ICP can be secondary to epidural or subdural hemorrhage. It is possible the patient may have fallen while playing in the playground. Increased ICP can present as the classic Cushing's triad: hypertension, inappropriate slowing of the heart rate, and irregular respirations (Cheyne-Stokes respiration). A further complication of increased ICP is epigastric discomfort. This is caused by the elevated ICP causing vagal stimulation, resulting in the secretion of gastric acid. Lastly, the patient's headache and non-bilious vomiting can also be ascribed to the increased ICP. D. Choice D is incorrect because gastroenteritis usually presents with fever, colicky abdominal pain, and diarrhea. It would also be atypical for the patient's mental status to be so adversely affected by gastroenteritis. More than 95% of gastroenteritis hospitalizations occur in children younger than 5 years, with the peak incidence between 3 and 24 months of age. The incidence tends to peak in winter. There can be both viral and bacterial causes for gastroenteritis. Classically, viral gastroenteritis will present with diarrhea in which the stool lacks blood or mucus. Bacterial gastroenteritis often causes diarrhea with gross blood or mucus present in the stool. E. Choice E is incorrect because a small bowel obstruction usually presents with bilious vomiting, abdominal distention, inability to pass flatulence, and moderate-to-severe abdominal pain. The pain is often paroxysmal, coming and going in 4 to 5 minute intervals. The patient's lack of a fever, however, is consistent with a GI obstruction. The most common causes of a small bowel obstruction are adhesions from a previous surgery or a hernia.

You are seeing a 1-month-old male who is < 3rd percentile for weight. He is breastfed every 2 hours and latches on well. However, he has frequent non-bilious episodes of vomiting that have been increasing over the past week despite his mother taking "reflux precautions." He does not have mucus or blood in his stool. Physical exam reveals a small, olive-sized mass in his abdomen. What is the most likely diagnosis? A Cleft palate B Pyloric stenosis C Cystic fibrosis D Non-organic failure to thrive E Munchausen syndrome by proxy

A. Choice A is incorrect. Children with structural anomalies of the palate typically present with difficulty feeding. This child appears to be latching on well, but has difficulty retaining the food once ingested. ***B. Choice B is correct because the history of frequent vomiting, poor weight gain, and the finding of an abdominal mass are consistent with pyloric stenosis. Children with pyloric stenosis often present at 3 weeks of age. C. Choice C is incorrect. Children with cystic fibrosis typically present with failure to thrive secondary to chronic malabsorption, with characteristic loose and malodorous stool. Lab testing reveals elevated sweat chloride. There may be a known family history.

A full-term, 6-week-old baby is brought to family physician for routine follow-up. At birth her weight, height, and head circumference were at 50th percentile; she is now at the 5th, 10th, and 25th percentiles, respectively. She and her twin sister are exclusively breastfed; their mother has maintained a rigid every-four-hour feeding schedule since birth. Physical exam reveals a thin but otherwise healthy infant. What is the most likely cause of this infant's failure to thrive? A Congenital heart disease B Inadequate caloric intake C Cystic fibrosis D Milk protein allergy E Inborn error of metabolism

A. Congenital heart disease is incorrect for two reasons. First, CHD is a less common cause of FTT than option B. Second, CHD severe enough to cause FTT would present with associated signs (such as murmur, cyanosis, or hepatomegaly) and symptoms (such as easy fatigability). ***B. Inadequate caloric intake is correct because it is the most common cause of FTT. Furthermore, we have reason to believe that this particular infant is not receiving adequate calories. Breastfed infants should eat Q2-3 until 3 months of age; this infant eats every four hours and shares the milk supply with her twin. Twins can thrive on exclusive breastfeeding, but it requires that the mother consume extra fluids and calories and ensure that the twins both get enough to eat. C. Cystic fibrosis is incorrect because it is a less common cause of FTT than option B. CF condition affects fewer than 1 in 3000 Caucasians and is much less common in people of other ethnicities. Furthermore, malabsorption due to CF usually results in diarrhea, steatorrhea, and constant hunger. Respiratory conditions such as chronic cough or recurrent pneumonias may be present as well. D. Milk protein allergy is incorrect because, while it is fairly common (frequency of 2 to 3%), this infant has no symptoms. Most common symptoms include diarrhea, vomiting, abdominal pain, and allergic reactions ranging from urticaria to anaphylaxis. E. An inborn error of metabolism is incorrect because this category of conditions is quite rare and definitely less common than option B. Furthermore, the infant would likely have other symptoms (such as lethargy, vomiting, etc.).

A 12-month-old previously healthy girl presents with cough and mild subcostal retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest x-ray demonstrates unilateral air trapping. What is the most likely diagnosis? A Croup B Pneumonia C Acute bronchiolitis D Foreign body aspiration E Asthma

A. Croup involves subglottic inflammation, typically presenting with inspiratory stridor and a "barky cough" (i.e., like a seal). B. While this patient presents with cough and increased work of breathing, she is afebrile, and auscultation of the chest does not reveal crackles or decreased breath sounds/area of consolidation, which would be consistent with pneumonia. Additionally, chest x-ray findings are not consistent with a lobar or more diffuse pneumonia. C. Acute bronchiolitis is a good thought, especially as this is the most common cause of wheezing in infant; however, if this were the diagnosis, the patient would most likely be febrile and chest x-ray would demonstrate scattered atelectasis and/or diffuse opacities from bronchial obstruction. *****D. Features of foreign body aspiration include unexplained wheezing and asymmetric breath sounds, as well as air trapping in one lung indicating unilateral airway obstruction. The right main bronchus is the more commonly obstructed due to anatomy (it is wider and more vertical than the left). E. While the finding of wheezing is consistent with asthma, this patient has wheezing only on one side. Along those lines, chest x-ray in an asthmatic patient would demonstrate global air trapping with hyperinflated lungs, rather than unilateral findings.

A 2-year-old girl is examined as an outpatient. While waiting for the pediatrician, her mother reads her a short book. When they are done, her mother asks her to take the book and return it to a bookshelf in the room. The child is not able to hold a pencil and cannot write her name. She can kick and throw a ball, but cannot jump in place. Which of the following best describes this child's development? A Delayed language B Delayed social skills C Advanced fine motor skills D Advanced gross motor skills E Age-appropriate development

A. Delayed language is incorrect: A 24-month-old child is expected to use pronouns inappropriately, but should be able to follow two-step commands such as taking a book and returning it to a location in the room. B. Delayed social skills is incorrect: At 24 months of age, children are able not only to listen to short stories, they also engage in parallel play. C. Advanced fine motor skills is incorrect: While a child can hold a pencil at 24 months, the grip is immature and the child imitates pencil strokes. Children can remove their pants and socks at this age, but need help to undress completely. D. Advanced gross motor is incorrect: Being able to jump in place is a 30-month-old milestone. Being able to throw a ball overhand is expected at 24 months of age. E. The child in this vignette is developmentally appropriate for her age.

You are on the nursery service when your team is called to evaluate a 1-day-old infant. The infant was born via NSVD at 40 weeks' gestation to a 38-year-old G1P1A0 mother who did not have access to prenatal care and did not receive prenatal testing. The infant weighed 7 lbs 12 oz at birth and had Apgar scores of 7 and 8. On exam the infant is sleeping comfortably. She is afebrile with normal vital signs but appears to have low tone on exam. You also notice her ears seem to be lower than her eyes and appreciate mild edema of the hands and feet. Additionally, you note a fluid-filled sac at the base of the neck that does not appear to interfere with breathing. A karyotype performed after birth reveals a chromosomal abnormality. Which of the following is the most likely cause of this patient's condition? A Down syndrome B Turner syndrome C Fetal alcohol syndrome D Benign neonatal hypotonia E Cystic hygroma

A. Down syndrome is incorrect, because infants with Down syndrome typically have physical findings that include epicanthic folds, flat facial profile, single palmar creases, redundant neck skin, and heart defects. Other findings including a gap between the first and second toes. While infants with Down syndrome can be hypotonic as this infant is, the patient in this scenario does not have the other physical findings consistent with Down syndrome. ***B. Turner syndrome is defined by the karyotype 45 XO. C. FAS can cause hypotonia, this infant does not demonstrate smooth philtrum, thin upper lip, or small palpebral fissures commonly seen in infants with FAS. FAS would not demonstrate a chromosomal abnormality on karyotyping. D. Benign neonatal hypotonia is incorrect because infant demonstrates facial features that suggest alternate etiology as well as abnormal karyotype. Typically, hypotonia of newborn, especially at one day after birth, is abnormal and could reflect illness (such as sepsis), or neurologic dysfunction at either the central or peripheral levels. E. A cystic hygoma can present with a fluid-filled collection around neck but is not associated with edema elsewhere and would not be associated with a chromosomal abnormality.

A 4-year-old patient with sickle cell disease presents for a well child evaluation. She has a history of 3 sickle cell vaso-occlusive crises in the past, including dactylitis and bone pain. She has been symptom-free for a few months and today she is feeling well. She is meeting her developmental milestones. She had an upper respiratory infection recently, but seems to be getting better now. She is up to date on her standard vaccinations up to 2 years including a full course (four doses) of Prevnar. What would you do for her today? A Echocardiogram and transcranial ultrasound B Quantiferon gold test C HPV vaccine D A dose of pneumococcal polysaccharide vaccine (Pneumovax). E Chest x-ray

A. Echocardiogram and transcranial ultrasound are recommended for patients with sickle cell disease. Echocardiogram screens for evidence of left ventricular hypertrophy and cardiomyopathy. Transcranial ultrasound is used to evaluate risk of stroke by measuring the middle cerebral artery flow. Routine transcranial ultrasound screening for these patients is recommended; echocardiogram is usually recommended for patient older than 21 years old, or for those with cardiopulmonary symptoms. B. A quantiferon gold test assesses previous exposure to TB by measuring for production of IFN by memory T cells from heparinized blood. This test is an acceptable way to measure whether a patient has been infected with TB, including latent infection, but is not indicated in this setting. C. HPV is recommended for children starting at age 11 years old. ***D. All children should routinely receive the Prevnar vaccine series. Patients with risk factors for pneumococcal sepsis, such as those with sickle cell disease, damaged spleen or asplenia, cochlear implants, CSF leaks, HIV, immunocompromise, chronic hear/lung disease, or those taking immunosuppressive medication should also receive 23-valent polysaccharide pneumococcal vaccine at age 2 years. E. Chest x-ray is not recommended when there are no current URI symptoms.

A woman brings her 8-year-old son to the pediatrician after witnessing him stare blankly into the distance at dinner previous week. He was unresponsive to her calling his name or any other stimuli, and it lasted for about 10 or 20 seconds. His teacher reports he does seem to daydream often in class but is able to keep up with schoolwork and excels in his studies. She doesn't note him being disruptive or impulsive in class. His mother is concerned about these blank stares and unresponsive episodes. Which of the following is the most likely diagnosis? A Generalized tonic-clonic seizure B Atonic seizure C Absence seizure D Simple partial seizure E Complex partial seizure

A. Generalized tonic-clonic seizure is most common type of seizure seen in children. These seizures begin acutely with tonic (rigid) stiffening of all extremities and upward deviation of the eyes. Tonic phase is followed by clonic jerks of all extremities. The patient then loses consciousness and may have urinary incontinence. The patient in this vignette did not have movement of his extremities and did not have urinary incontinence. B. Atonic seizure, also called drop seizures or drop attacks, consists of loss of motor tone, where patients have a brief lapse in muscle tone. These seizures can occur while walking, standing, or sitting, and have a characteristic head drop (the neck muscles releasing). These seizures last about fifteen seconds. The patient in the vignette did not have symptoms of an atonic seizure. C. The patient is having absence seizures. Absence seizures are characterized by loss of awareness of surroundings ("blank stare" or "in another world") and automatisms (e.g., eye-fluttering or lip-smacking). These patients do not lose consciousness or have loss of tone. Absence seizures should also be differentiated from ADHD, since children with ADHD also can be inattentive or seem to be daydreaming. However, since patient in vignette still does well in school and does not have other signs of ADHD, it is most likely an absence seizure. An EEG will confirm the diagnosis. D. Simple partial seizure is a seizure localized to a small region of the brain. Patients do not lose consciousness. Based on region of brain the seizure is occurring in, the patient will exhibit focal symptoms (e.g., altered hearing or smelling, labored speech, etc.). If patients have motor symptoms, it is usually localized to one extremity. E. Complex partial seizure is characterized by impairment of consciousness. These seizures are similar to simple partial seizures except patients lose consciousness.

Frank is 16-year-old male brought in by his mother who complains that her son "looks much younger than his age." She states that until about four years ago, she did not notice much difference between Frank and his friends. However, in the past two years, Frank has become the shortest person in his class. Frank's mother is concerned that he has a "hormone problem" and wants to know how she can tell if he has begun puberty. What is usually the first sign of puberty in a male? A Growth of the penis B Appearance of pubic hair C Testicular enlargement D Growth spurt E First ejaculations

A. Growth of the penis occurs with growth of the scrotum, and usually occurs around 13-14 years of age. It normally follows pubic hair appearance and precedes first ejaculations. B. Pubic hair appearance occurs around 12 years of age, and is usually the second sign of puberty following testicular enlargement. It precedes growth of the penis and scrotum. C. CORRECT. The first sign of puberty in a boy is testicular enlargement. The onset of puberty is quite variable, but usually occurs between 10 and 15 years for boys. It is rare for boys not to have begun puberty by the age of 16. To assess whether or not a male has entered puberty, one must know the order of the appearance of secondary sexual characteristics. D. A growth spurt is usually not appreciated until at least 14 years of age for most boys. It is one of the last secondary sexual characteristics to be noted, following first ejaculations. E. First ejaculations usually occur around 13-14 years of age. These follow growth of the penis and scrotum, and precede a growth spurt.

Alex is a 6-year-old boy who presents to the clinic with a chief complaint of acute onset of bruising. He is afebrile, and his mother reports that he recently had a URI. He was born at full-term and has never been hospitalized. He was circumcised at birth with no problems with bleeding. No one in his family has any chronic medical problems. There have been no serious childhood illnesses or deaths. No one has a history of easy bruising or bleeding. On exam you find that he has a purpuric rash on his buttocks and legs. His urinalysis reveals 15 to 20 RBCs/hpf. Which of the following additional findings would NOT be consistent with the likely diagnosis? A Elevated serum IgA B Blood in the stool C Colicky abdominal pain D Pain in his knees and ankles E Low platelets

A. HSP is an IgA-mediated vasculitis involving the skin, joints, GI tract, and kidneys. Serum IgA may be elevated, occurring in 50% of patients. B. Since IgA immune complexes in HSP also attack the GI vessels, around 67% of patients have GI bleeding, either occult blood or grossly bloody stool. C. Abdominal pain occurs in 50 to 75% of HSP patients, as a result of the immune attack on the GI vessels, as described above. D. Arthralgias, mainly of the knees and ankles, seen in about 75% of children with HSP. ****E. Thrombocytopenia is not characteristic of HSP, but is commonly seen in idiopathic thrombocytopenic purpura (ITP). Decreased platelets are often the delineating finding between HSP and ITP.

A 4-year-old child is refusing to walk over the course of a week. Her mother recalls that she fell off her bike yesterday. On exam, she is afebrile, but has decreased ROM of her hip. You review her file and note that she is up-to-date on her immunizations and she was last seen three weeks ago for a self-limited episode of diarrhea that she developed while visiting family in rural Mexico. Aspiration of her affected hip joint reveals slight increase in inflammatory cells but normal chemistries and a negative gram stain. Culture is pending. Which of the following is the most likely diagnosis? A Osteomyelitis B Trauma C Transient synovitis D Reactive arthritis E Septic arthritis

A. Incorrect. The gradual onset of refusing to walk is consistent with osteomyelitis, and only half of patients present with fever. However, this patient is not acutely ill as one would expect with hematogenously acquired osteomyelitis. While this is a possible diagnosis, it is further down on the differential diagnosis. B. Children who present with limp secondary to trauma may not have any findings visible on x-ray for a few weeks. Though a fall from a bike could certainly aggravate a weakened bone or joint, this patient's limp developed over the course of a week. C. While transient synovitis could certainly present with pain, it is more likely to present acutely in the absence of other complaints. A recent URI, not gastroenteritis, is most consistent with a transient synovitis. ***D. Correct. The patient likely had a recent case of mild to moderate gastroenteritis in Mexico, which may have been 2ary to an bacterial enteritis such as shigella, or campylobacter. In reactive arthritis, joint inflammation occurs a few weeks later because antibodies made during the illness are attacking the joint. While several inflammatory cells would be seen in the aspirate, importantly, the cultures will turn out to be negative. E. Although on exam it may be difficult to distinguish septic from reactive arthritis, in septic arthritis the culture is often positive.

8-year-old Jenny presents complaining of intermittent, crampy abdominal pain that has persisted over the last three months. The pain is nonspecific, nonfocal, and not associated with any other systemic symptoms such as fever, chills, weight loss, nausea, vomiting or diarrhea. The pain also seems to occur more frequently during the week and not as often on weekends. The abdominal exam is normal. Jenny is given a diagnosis of functional abdominal pain and scheduled for a one-month follow-up. Six months later, she returns to the clinic complaining of more frequent, more severe abdominal pain that is waking her up at night. She also reports a week of diarrhea containing mucus and blood without associated fever or vomiting. Review of her growth chart demonstrates a slowing of weight gain and a drop in height velocity. What is the most likely diagnosis? A Irritable bowel syndrome B Giardiasis C Celiac disease D Crohn's disease E Henoch-Schonlein purpura (HSP)

A. Irritable bowel syndrome is a sxs-based diagnosis with chronic abdominal pain, discomfort, bloating, and alteration of bowel habits. It is often a dx of exclusion, with no known organic cause. Other symptoms include diarrhea or constipation. B. Giardiasis is a parasitic disease caused by flagellate protozoan that inhabits the digestive tract leading to decreased appetite, diarrhea, hematuria, loose or watery stool, stomach cramps, bloating, excessive gas, and burping. Many people with giardia infection are asymptomatic. Untreated symptoms may last six weeks or longer. Diagnosis is made via stool microscopy, ELISA, or entero-test with gelatin capsule and thread. C. Celiac disease is an autoimmune disorder of the small intestine characterized by diarrhea, failure to thrive, and fatigue. A rash known as dermatitis herpetiformis (an autoimmune cutaneous eruption) can also occur. ***D. Crohn's disease is most consistent with this presentation, as it affects GI tract from mouth to anus, leading to abdominal pain, diarrhea (can be bloody), vomiting, or weight loss. Extraintestinal symptoms include skin rashes, arthritis, and fatigue. Fever, fistula, and perianal complications are also common. E. Henoch-Schonlein purpura (HSP) presents with abdominal pain, palpable purpura on the lower extremities, joint pain, and often kidney involvement. It is an acute systemic vasculitis characterized by deposition of immune complexes containing IgA. Abdominal pain is colicky often with nausea, vomiting, constipation, or diarrhea.

A 4-week-old female infant presents to clinic for a well child check. This infant had an uneventful delivery by NSVD at full term and subsequent normal neonatal screen. The nurse reports that her growth is a concern, with weight at 3.0 kg (< 3rd percentile) and weight for height at < 3rd percentile. Mom denies any drinking or drugs since before this pregnancy and says she has been breastfeeding Q2-3 hours and supplementing with appropriately mixed formula 1-2x a day. She does report the baby seems to have issues latching and some possible gasping between suckles. There has been no diarrhea, hematochezia, vomiting, or fevers. The vital signs and exam (apart from a thin infant) are normal. The mother's affect is flat, and she seems anxious when you ask her about her infant. What is the most likely diagnosis for this infant's failure to thrive? A Malabsorption B Gastroenteritis C Milk protein allergy D Congestive heart failure E Failure to thrive due to inadequate caloric intake

A. Malabsorption typically presents with poor weight gain and loose stools despite good caloric intake. This infant has poor caloric intake with constipation, making this diagnosis unlikely. B. Gastroenteritis typically presents with loose stools, emesis, and fever. This infant has none of these symptoms. C. Milk protein allergy typically causes bloody stools rather than isolated poor weight gain. The patient does not have bloody stools or other signs of allergy or formula intolerance. Milk protein allergy is less common but still occurs in breastfed infants. D. Congestive heart failure is important to consider in any child with failure to thrive, but this child has no signs of CHF such as tiring with feeds, sweating, or tachypnea, tachycardia, or hepatomegaly. ****E. This infant is likely not consuming adequate calories to grow. The mother or primary caregiver may neglect proper feeding of infant because of preoccupation with the demands or care of others, her own emotional problems, substance abuse, lack of knowledge about proper feeding, or lack of understanding of infant's needs. It is also important to assess mother for post-partum depression. Standardized screening tools, such as Edinburgh, are used routinely in pediatric office settings for this purpose.

A 12-year-old girl presents to her PMD complaining of a headache of gradual onset x 3 hours, non-provoked and described as a "big rubber band around my whole head" and a 5/10 on pain scale. The pain is not throbbing, and no associated photophobia, nausea or vomiting. Patient is afebrile, and no neurologic deficits during physical exam. Her mother states pain is typically relieved with ibuprofen, but her mother is concerned that patient may have migraines because she has a few headaches every month after school. The child is otherwise healthy. What is the most likely cause of this girl's headaches? A Migraine B Tension-type headache C Brain tumor D Sinusitis E Pseudotumor cerebri

A. Migraines are typically described as having "throbbing"-type pain and may also be associated with nausea and/or vomiting with photophobia and phonophobia. Pain is often described at 10/10 and is debilitating. ***B. Tension-type headaches are often bilateral and involve the forehead, temporal areas, or back of the head. Tenderness of the posterior muscles of the neck may also be present. They should be responsive to NSAIDs. Stress can give rise to a tension headache, and this is consistent with this patient developing headaches after school. C. A brain tumor is unlikely to present without focal neurological findings, and short duration of symptoms do not warrant further workup for this. In addition, the headache is less likely to be relieved with NSAIDs and would not occur only a few times a month. D. The patient is otherwise healthy and did not complain of any nasal stuffiness, rhinorrhea, or sore throat with postnasal drip, making sinusitis unlikely. E. Pseudotumor cerebri presents as symptoms of increased intracranial pressure—headache, nausea, blurred vision, diplopia, photophobia, and tinnitus—that occur in the absence of a intracranial mass. CT/MRI will be negative, but opening pressures are elevated on lumbar puncture. It typically occurs in obese women of childbearing age, with the median age of diagnosis around 30 years. While the cause is unknown, other risk factors include OCPs, growth hormone, excess vitamin A, and discontinuing steroids.

Johnny is brought to your office by his parents for his 18-month well child check. His family recently moved into town, and this is first time you are seeing him. Per mom, he was born at 32 weeks, and details of his neonatal course are not clear. Parents share that he is not walking and they are very concerned. Johnny has met his social and language developmental milestones. Physical exam reveals spasticity, exaggerated deep tendon reflexes, and clonus in both of his lower extremities. An MRI of the brain is ordered, and the radiologist reports findings of periventricular leukomalacia. What is the most likely diagnosis? A Niemann-Pick disease B Spastic diplegia C Athetoid cerebral palsy D Autism spectrum disorder

A. Neimann-Pick disease is a neurodegenerative disease that can present in children between the ages of 6mos-2 years. It causes global delays as well as regression of milestones. Other signs and sxs include hepatosplenomegaly, ILD, and macular cherry red spot. ***B. Spastic diplegia is a form of cerebral palsy, a non-progressive static encephalopathy characterized by delays in motor development. It may be associated with periventricular white matter abnormalities that are thought to be due to ischemia. These changes can be visualized on MRI. In spastic diplegia, the motor abnormalities are often greater in the legs than in the arms. C. Athetoid cerebral palsy involves motor deficits of entire body, not just legs. It is often caused by perinatal asphyxia and kernicterus, both of which damage the basal ganglia, cerebellum, and/or thalamus. D. Children with autism present with delays in language and social interaction, rather than with motor delays. Motor development is typically normal.

Rashid is a 5-week-old baby boy who presents to clinic with 4 days of repeated, forceful, non-bilious, non-bloody vomiting without diarrhea. He has 8 to 9 episodes of vomiting per day immediately following breastfeeding. The episodes started 2 weeks after the entire family suffered from severe viral gastroenteritis. His birth history is uncomplicated (full term, NSVD, unremarkable 30-week ultrasound) and birth weight was 3.6 kg (50th percentile). On exam, his vitals are: T 36.7°C, HR 185, BP 85/45, RR 36, Wt 4.1 kg (25th percentile). On exam, his eyes are moderately sunken without production of tears, his lips are cracked, and his throat is without erythema. His capillary refill is ~3 seconds, and his pulse is thready. What is your first step in management? A. Close observation in the office for 6 hours and encourage PO intake until vitals normalize. B. Intravenous LR solution of 20mL/kg boluses until baseline clinical status is achieved, then 100 mL/kg oral rehydration solutions over next 4 hours. C. Intravenous 20 mL/kg boluses of ¼ normal saline solution until baseline clinical status is achieved, then closely monitor vitals for 6 hours while encouraging PO formula intake. D. Observe for 6 hours with normal PO intake and administer 60-120 mL of oral rehydration solution for every episode of vomiting. E. Administer 75 mL/kg of oral rehydration solution over 3-4 hours and 60-120 mL of oral rehydration solution for every episode of vomiting.

A. Not appropriate measures for treating this child's severe dehydration. Signs of severe dehydration include lethargy or unconsciousness on exam, poor PO intake, tachycardia, weak or nonpalpable pulses, deep breathing, deeply sunken eyes, parched mouth and tongue, reduced skin turgor, and cold/cyanotic extremities. In cases like this, the child must be placed on immediate IV fluids with 20 mL/kg boluses until vitals and mental status normalize. ***B. LR solution or NS in 20 mL/kg boluses until UO is established and mental status improves, then 100 mL/kg oral rehydration solutions over next 4 hours. This follows current CDC guidelines for treating a severely dehydrated child. Intravenous hydration with 5% dextrose ½ normal saline at 2x maintenance fluid rates may be substituted for the oral rehydration solution if the child is not tolerating PO intake. To replace ongoing losses, the CDC recommends 60-120mL of oral rehydration solution per diarrheal/emetic episode (through a NGT if necessary). C. One quarter normal saline (1/4 NS) is a hypotonic solution, and would not be ideal for the treatment of dehydration due to emesis. The recommended therapy to correct severe dehydration is to give 20 mL/kg boluses of isotonic solution and to reassess for clinical improvement following each administration. Once the patient is stable and back to baseline, then continue IV hydration with 5% dextrose ½ normal saline at twice maintenance fluid rates OR give 100 mL/kg oral rehydration solution over 4 hours. D. This would not be a recommended treatment for the severely dehydrated child since it relies on normal PO intake. However, replacement of losses strategy is correct for all patients < 10 kgs. E. IV rehydration is key to initial fluid resuscitation in the severely dehydrated, so this treatment would not be sufficient. However, this plan would be appropriate for mild to moderately dehydrated patients.

A 3-year-old girl presents to the ED with sudden onset difficulty walking. She does not have a fever, headache, nausea, or vision changes, but two weeks ago she had a runny nose, a fever, and a rash. Msk exam reveal no abnormalities of lower extremities. Neuro exam reveals bilateral horizontal nystagmus, wide based stance and swaying, and bilateral overreaching on finger to nose test. An LP is performed which reveals a normal CSF. Which of the following is the most likely diagnosis? A Opsoclonus-myoclonus syndrome B Hydrocephalus C Infectious cerebellitis D Post-infectious cerebellitis E Migraine headache

A. Opsoclonus-myoclonus syndrome is incorrect. It is 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. B. Hydrocephalus is incorrect because the presentation tends to be more gradual or insidious in onset and it is usually associated with headache and vomiting. C. Infectious cerebellitis is incorrect because it presents with fever and sometimes mental status changes. Pathogens that cause this may include EBV, mumps, and enterovirus. ***D. Post-infectious cerebellitis is correct. This typically presents in a younger child with ataxia, nystagmus, vomiting and sometimes dysarthria. It is believed to be an autoimmune response leading to demyelination of the cerebellum occurring several weeks after a viral infection such as varicella or coxsackie virus. E. Migraine headache is incorrect because this would present with a headache. Although basilar artery migraines and hemiplegic migraines may present with acute ataxia, headache is an accompanying symptom.

Luanne is a 15-year-old female who presents with 3 hrs of abdominal pain and 2 episodes of non-bilious, non-bloody vomiting. She rates her pain at 8/10 and describes it as constant, located mainly in middle of her belly but somewhat present throughout her abdomen. It is worse with coughing and moving. She has never had pain like this before, and has had no appetite since pain started. She is sexually active with her boyfriend of three months, always uses condoms, and has not been tested for STIs. She is due to start her period next week. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mmHg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Her WBC and CRP are within normal limits. Based on the information above, what is the most likely diagnosis? A Ovarian torsion B Pelvic inflammatory disease C Ectopic pregnancy D Appendicitis E Cholecystitis

A. Ovarian torsion is described as intermittent stabbing pain in lower abdominal or pelvis. Torsion is often 2ary to an ovarian mass, such as a neoplasm or corpus luteal cyst, which is occasionally appreciated on exam. Nausea and vomiting are very common findings as well. Ultrasound is essential to initial workup. Given that Luanne has periumbilical pain, tenderness at McBurney's point, and no palpable masses on pelvic exam, ovarian torsion is a less likely diagnosis. B. PID is definitely a possibility given her sexual history, lack of STI screening, and adnexal pain. However, pain is often post-coital and also first occurs during or immediately following menstruation. Another key finding is mucopurulent discharge and cervical motion tenderness, both of which are absent in Luanne. RUQ pain and a fever (present in 50% of patient) are other signs not seen in this case. C. Patients with ectopic pregnancy typically present with painless vaginal bleeding six to eight weeks after their last menstrual period. The pain is described as crampy pelvic pain, and it is often associated with nausea. Diffuse abdominal pain is also present if rupture and intraperitoneal bleeding occurs. Given that Luanne is three weeks from her last menstrual period, reports no vaginal bleeding, and her pain is intense and located in the middle of her abdomen, an ectopic pregnancy is less likely. ****D. Appendicitis is most common condition in children requiring immediate surgical intervention, but often presents differently than in adults (especially in infants). Aspects of their atypical presentation include lack of migration of pain to RLQ, negative Rovsing's sign, and involuntary guarding and fever without perforation. In school-age children who can articulate pain, they often describe pain with movement or coughing (cat's eye sign). Also, rebound tenderness was found to be neither sensitive nor specific in pediatric population, while in the adult population it is one of the most accurate PE findings (86%). Luanne is of the older pediatric population, and so will present with a more typical appendicitis. Her sudden onset of intense pain at the umbilicus with vomiting, anorexia, and tenderness at McBurney's point are all classic findings. The more atypical signs include diffuse pain centered below the umbilicus, and rebound tenderness that might point to a perforation (more likely, it is part of the atypical pediatric presentation given her normal WBC study). Another atypical aspect of her exam is her adnexal pain during the pelvic exam, which could be due to the degree of inflammation and the positioning of her appendix. The key take-away point is to have a high index of suspicion for appendicitis for pediatric patients with abdominal pain given their atypical presentation. E. The pain of cholecystitis is steady, most often present in the RUQ, and can radiate to the right shoulder. It can worsen with ingestion of fat-rich foods, and often causes anorexia with episodes of nausea and vomiting. It is much less common in children than adults. Given Luanne's presentation, age, and exam, cholecystitis is very low on our differential

Luanne is a 15-year-old female with three hours of abdominal pain and two episodes of non-bilious, non-bloody vomiting. She rates her pain at 8/10 and describes it as constant and located mainly in the middle of her belly, but somewhat present throughout her abdomen. It is worse with coughing and moving. She has never had this pain before, and has had no appetite since the pain started. She is sexually active with her boyfriend of three months, always uses condoms, and has not been tested for STIs. Her last menstrual period was two weeks ago. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mm Hg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spin and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Her WBC and CRP are within normal limits. Based on the information above, what is the most likely diagnosis? A Ovarian torsion B Pelvic inflammatory disease C Ectopic pregnancy D Appendicitis

A. Ovarian torsion is more common in the post-menopausal population, though it can present in any age group. It is described as intermittent stabbing pain in the lower abdomen or pelvis. Torsion is often secondary to an ovarian mass, such as a neoplasm or corpus luteal cyst, which may occasionally be appreciated on exam. Nausea and vomiting are very common findings as well. Ultrasound is essential to initial workup. Given Luanne's pain localized around her belly button, her tenderness at McBurney's point, and lack of palpable masses on pelvic exam, ovarian torsion is a less likely diagnosis. B. Pelvic inflammatory disease is definitely a possibility given Luanne's sexual history, lack of STI screening in the past, and adnexal pain. However, this pain is often post-coital and also first occurs during or immediately following menstruation. Another key finding is mucopurulent discharge and cervical motion tenderness, both of which are absent in Luanne. RUQ pain and a fever (present in 50% of patients with PID) are other signs that are not reported in this case. C. Patients with an ectopic pregnancy typically present with painless vaginal bleeding six to eight weeks after their last menstrual period. The pain is described as crampy pelvic pain, and it is often associated with nausea. Diffuse abdominal pain is also present if rupture and intraperitoneal bleeding occurs. Given that Luanne is two weeks from her last menstrual period, she reports no vaginal bleeding, and her pain is intense and located in the middle of her abdomen, an ectopic pregnancy is less likely. D. Appendicitis is the most common condition in children requiring immediate surgical intervention, but often (especially in infants) presents differently than in adults. Aspects of their atypical presentation include lack of migration of pain to the RLQ, negative Rovsing's sign, and involuntary guarding and fever without perforation. School-age children who can articulate the pain often describe pain with movement or coughing (cat's eye sign). Also, rebound tenderness was found to be neither sensitive nor specific in the pediatric population, while in the adult population it is one of the most accurate PE findings (86%). Luanne is of the older pediatric population, and so will present with a more typical appendicitis. Her sudden onset of intense pain at the umbilicus with vomiting, anorexia, and tenderness at McBurney's point are all classic findings. The more atypical signs include diffuse pain centered below the umbilicus, and rebound tenderness that might point to a perforation (more likely, it is part of the atypical pediatric presentation given her normal WBC). Another atypical aspect of her exam is her adnexal pain during the pelvic exam, which could be due to the degree of inflammation and the positioning of her appendix. The key take-away point is to have a high index of suspicion for appendicitis in pediatric patients with abdominal pain given their atypical presentation.

A 16-year-old obese Caucasian female with a history of irregular menses presents to the ED with severe abdominal pain and AMS. She uses IV drugs weekly. She has regular unprotected sexual intercourse with multiple male sexual partners. She has experienced fevers, nausea, vomiting, and right shoulder pain and reports no vaginal bleeding. She has not regularly seen a physician for years. Only bedside studies are performed. Vitals are T 38.0 C, BP 90/60 mmHg, P 120 bpm, R 20 bpm. Qualitative B-hCG is positive, and hemoglobin is 7 g/dL. On exam, she is in apparent distress and has difficulty answering questions. Auscultation of chest is clear. The abdomen is somewhat rigid with tenderness in the right lower quadrant as well as guarding and rebound tenderness. On pelvic exam, there is cervical motion tenderness but no bleeding or masses noted. What is the most likely diagnosis? A Pelvic inflammatory disease B Ruptured ectopic pregnancy C Fitz-Hugh-Curtis syndrome D Appendicitis E Hepatitis

A. Pelvic inflammatory disease (PID) is a possibility, as indicated by the patient's sexual history and cervical motion tenderness. Symptoms of PID include lower abdominal or pelvic pain, vaginal discharge, fever, fatigue, nausea, vomiting, diarrhea, dysuria, and dyspareunia, among other symptoms. Although PID may occur during pregnancy, it would not account for the low hemoglobin, peritonitis, or vital signs suggesting fluid loss/bleeding. ***B. The patient likely has a ruptured right-sided ectopic pregnancy, as indicated by + pregnancy test and hemodynamic instability. Hemorrhage into peritoneum may irritate the peritoneum and cause referred pain to the right shoulder. Cervical motion tenderness may also be found. Patients may experience nausea, vomiting, and fever. C. Fitz-Hugh-Curtis syndrome is a possible complication of pelvic inflammatory disease, a possibility given the patient's sexual history. The abdominal pain would be felt in the right upper quadrant and may be referred to the right shoulder if the peritoneum becomes irritated. Although Fitz-Hugh-Curtis syndrome may occur during pregnancy, Fitz-Hugh-Curtis syndrome would not account for the low hemoglobin, peritonitis, or vital signs suggesting fluid loss/bleeding. D. Appendicitis would present as right lower quadrant pain. Symptoms include nausea, vomiting, fever, diarrhea, and constipation. On physical examination, the patient may have peritoneal signs. It is unlikely that appendicitis would cause low hemoglobin or hemodynamic instability. E. With acute hepatitis, patients may present with anorexia, nausea, vomiting, fatigue, malaise, and fever, among other symptoms. Lab studies would reveal elevated AST and ALT. History may be positive for iv drug use, immigrant Asian mother, or travel. The pain would be felt in the right upper quadrant and may be referred to the right shoulder if the peritoneum becomes irritated. The patient would unlikely be hemodynamically unstable and severely anemic.

Katie is a 5-year-old girl with 10-day history of swelling of her face, especially around the eyes. Her mother has also noticed that her pants have become too tight for her, and that she has gained nearly 5 pounds despite a decreased appetite. About a week prior to the start of the swelling, her mother recollects an episode of rhinorrhea, cough, and sore throat. Urinalysis shows no RBCs or casts, but you have no other data from urinalysis due to a lab error. On exam, temperature is 98.8 F, HR is 95 bpm, blood pressure is 95/65 mmHg. Her face is diffusely swollen. Heart and lung exams are normal. Abdominal exam shows some abdominal fullness but no masses or organomegaly. Both feet appear slightly puffy. Which of the following is the most likely cause? A Sinusitis B Nephritis C Nephrotic syndrome D Congestive heart failure E Allergic reaction

A. Periorbital swelling and redness can result from inflammatory edema secondary to ethmoid, frontal, or maxillary sinusitis. Sinusitis or allergic rhinitis could cause more prolonged symptoms, but are usually accompanied by cough or runny nose. Sinusitis would not be associated with increase in weight, or cause increasing abdominal girth. B. Nephritis classically presents with proteinuria, hematuria, and hypertension. This patient's BP is normal. Although UA unfortunately was inconclusive on level of proteinuria, there was no hematuria. ***C. The constellation of history and physical exam findings, with a recent viral infection and subsequent edema, suggests nephrotic syndrome. Minimal change disease is the most common form of nephrosis in pediatrics. Changes in the podocytes of glomerular apparatus allow significant proteinuria (> 3.5 g/day), which leads to hypoalbuminemia and eventually interstitial edema and ascites. This would explain the patient's periorbital swelling, increasing abdominal girth (ascites), and weight gain (pure fluid overload). D. CHF could cause generalized edema due to poor ventricular function, but cardiothoracic exam would be expected to be abnormal, with crackles in lungs and murmur or gallop over precordium. E. Periorbital swelling from an allergic reaction is usually abrupt in onset, and often accompanied by an urticarial rash. This patient has no rash, and the distended abdomen is not explained by an allergic reaction.

A 12-year-old male presents to the ED with complaints of anorexia, weight loss, and persistent cough, with nocturnal coughing fits that have been waking him from sleep for the past three weeks. He denies fever, chills, myalgia, sore throat, or rhinorrhea. The patient presented to his primary care physician one week prior with the same complaint, and was treated with amoxicillin and bronchodilator therapy. His chest x-ray was negative for infiltrates at that visit. The patient's symptoms did not improve with this regimen. The cough became more frequent, sometimes causing emesis. Which of the following is the most likely diagnosis? A Reactive airway disease B Infection with Bordetella pertussis in the catarrhal stage C Infection with Bordetella pertussis in the paroxysmal stage D Atypical pneumonia due to Mycoplasma pneumoniae E Laryngotracheobronchitis

A. Reactive airway disease would most likely have improved with bronchodilator therapy. In addition, you would not expect to see anorexia or weight loss with reactive airway disease. B. The catarrhal stage of pertussis lasts one to two weeks and is often indistinguishable from URI. In this patient the presenting symptoms have been an ongoing problem for more than three weeks. C.**** The paroxysmal stage of pertussis lasts four to six weeks and is characterized by repetitive, forceful coughing episodes, followed by massive inspiratory effort. This massive inspiratory effort is what results in the characteristic "whoop"-sounding cough. This is consistent with the patient's presentation and duration of illness. The forceful coughing fits in pertussis can even lead to conjunctival hemorrhages and pneumothoraces from the increased intrathoracic and intracranial pressures from Valsalva. D. Mycoplasma pneumonia would be expected to be associated with fevers and findings on chest x-ray and lung exam. E. Croup (laryngotracheobronchitis) presents with difficulty breathing and a "seal bark" cough and usually lasts a week or less. Croup also is usually associated with fever.

Kenny is a 12 year-old male who comes to your clinic with a chief complaint of crampy abdominal pain. His mother tells you that sometimes he wakes up from sleep due to the pain. He also has diarrhea that sometimes has blood in it. When asked about stressors in his life, his mother sighs and tells you that she is recently divorced and had to move Kenny to a new school. On physical exam, he appears small for his age. Abdomen is soft, non-distended, but tender to palpation at the RUQ. On rectal exam, you note anal skin tags and an anal fistula. Skin exam shows red tender nodules on his shins. Labs show a microcytic anemia. What is the next best step in management? A Reassure and refer to psychiatry B Start omeprazole and antibiotics C Colonoscopy D Start mesalamine E Obtain IgA endomysial antibody and IgA anti-tissue transglutaminase antibody

A. Reassure and refer to psychiatry is incorrect. This is the right management for functional abdominal pain, which is the most common cause of abdominal pain in this age group. However, bloody diarrhea cannot be explained by functional abdominal pain and suggests a more serious diagnosis. B. Start omeprazole and antibiotics is incorrect. This is the correct management of PUD caused by H. pylori. PUD cannot account for the perianal disease, diarrhea, or erythema nodosum. ***C. Colonoscopy is the best answer. Kenny likely has IBD (Crohn's disease or ulcerative colitis [UC]). He has crampy abdominal pain and intermittently bloody diarrhea, crampy abdominal pain (that wakes him up at night), perianal disease, and erythema nodosum. He also has microcytic anemia, likely from chronic blood loss. Colonoscopy with biopsies will allow you to diagnose Crohn's disease (or UC) prior to treating it. The diagnosis begins with a colonoscopy to obtain tissue biopsies as well as blood tests (p-ANCA, ASCA). D. you have not yet established a diagnosis. E. celiac disease would not present with blood in the stool or other extraintestinal signs. Celiac can be associated with dermatitis herpetiformis, an itchy, papulovesicular rash.

An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy? A Only rescue inhaler PRN B Low dose inhaled corticosteroids C Medium dose inhaled corticosteroids and course of oral corticosteroids D Medium dose inhaled corticosteroids, LABA, and course of oral corticosteroids E Course of oral corticosteroids

A. Rescue inhaler (a short-acting beta agonist) i PRN is incorrect because this treatment is indicated in patients with intermittent asthma and have symptoms fewer than two days a week or two nights a month ***B. Low dose inhaled corticosteroid is correct because this patient has mild persistent asthma. His symptoms occur 3-6 days/week and 3-4 nights/month. C. Medium dose inhaled corticosteroids with a course of oral corticosteroids is incorrect, because it would be indicated in a patient with moderate persistent asthma when symptoms occur daily and more than one night per week. D. Medium dose inhaled corticosteroids, LABA, and oral corticosteroids is incorrect because this patient does not have severe persistent asthma. E. A course of oral corticosteroids alone is incorrect. Asthma needs to be managed long term to prevent exacerbations. An inhaled corticosteroid is indicated.

A 10-year-old male comes to clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup? A Response to inhaled beta-agonist B Hyperinflation in one lung field C Alevolar consolidation in the RLL D Positive PCR for pertussis E Fluffy bilateral infiltrates and a large heart on chest x-ray

A. Response to an inhaled beta agonist is a good test for RAD or asthma. Asthma is diagnosed clinically, usually in a school-aged child, with a history of recurrent wheezing. Associated findings might atopic stigmata, such as allergic rhinitis, food allergy, and atopic dermatitis. Without details in the history, asthma is a less likely diagnosis in this setting, and in the absence of wheezing, asthma is even less likely. B. This would be consistent with a foreign body aspiration which could produce cough and fever (if bacterial superinfection occurs). This diagnosis is usually considered in younger children. Constitutional symptoms (fatigue, decreased eating) make pneumonia a better diagnosis in this clinical setting. ***C. Pneumonia is most likely cause symptoms and a chest x-ray would be a great confirmation of your suspected diagnosis. Eliciting a complete history might reveal history of an upper respiratory infection. Localization of crackles (discontinuous inspiratory sounds) to one lobe makes pneumonia more likely. D. Pertussis can produce a lengthy cough illness, but is not associated with fever or lung findings. E. Pulmonary edema due to CHF is a symmetrical process and less likely to present with a unilateral lung finding. Pulmonary edema should be suspected with crackles, but this clinical setting leaves pulmonary edema low on our differential.

A 10-month-old male is brought to emergency room by his very concerned and frantic grandmother. Earlier that day, she retrieved the child from his mother's new boyfriend, who had been watching him while his mother was at work. The grandmother makes it very clear she does not approve of this new boyfriend, and she is concerned that he is rough with her grandson. She demands that her grandson be worked up for injuries and that a restraining order be placed against the boyfriend. Which of the following finding does NOT indicate that a child is being physically abused? A Retinal hemorrhages on fundoscopy B A concaved, crescent-shaped mass on head CT C A spiral fracture of the tibia D Two posterior rib fractures E A metaphyseal fracture of the wrist

A. Retinal hemorrhages are commonly found in victims of shaken baby syndrome. Of these patients, 65% to 90% typically present with diffuse, bilateral retinal hemorrhages. This typically occurs in younger infants. B. Subdural hematomas occur when bridging vessels are torn during the act of shaking or throwing a baby. It is achieved by extreme rotational cranial acceleration force to the brain. Diffuse axonal injury to the neurons also occurs. CT scans and MRIs can detect the bleed. ****C. Also called a "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. D. Posterior rib fractures are associated with shaken baby syndrome. As adult squeezes the child's thorax in the process of shaking the child, the posterior ribs are at risk of being fractured. E. Metaphyseal fractures, also called "bucket handle" or corner fractures, are caused by torsional force on the limb, or by violent shaking. While these can occasionally occur in older children who test the limits of their limbs, this would be unlikely in an 10-month-old. You can never be reassured by a metaphyseal fracture, and should always have child abuse on your differential when this type of fracture is apparent.

A 39-year-old G2P1 woman with a pre-pubertal 10-year-old boy with intellectual disability comes to the clinic for information on prenatal screening. The 10-year-old boy was born with large ears and long face but no other congenital malformations. The mother is worried that she will have a second child with similar problems. If she were to have a second male child with developmental impairment, what would be the most likely reason if maternal serum testing and fetal ultrasound were both normal? A Down syndrome B Trisomy 13 C Fragile X syndrome D Turner syndrome E Klinefelter syndrome

A. Risk of Down syndrome is increased with advance maternal age, but prenatal screening would show abnormal maternal serum values with or without abnormal fetal ultrasound findings. B. Patients with Trisomy 13 would not have large ears and long face, but would present with severe impairments at birth. ***C. Fragile X syndrome is the most common familiar cause of developmental impairment and is due to an abnormal number of trinucleotide repeats. These children present with large ears, long face and mandible and, after puberty, large testicles. D. Turner syndrome is not correct given the child's male sex. Individuals with Turner syndrome have normal IQ. E. Patients with Klinefelter syndrome have IQs that vary around the low-normal range, but typically have no stereotypical physical features other than low muscular bulk due to decreased testosterone levels.

A 3-year-old male presents with fever to 103 F for the past week, injected eyes, and a refusal to walk for the past two days. On physical exam, you note conjunctival injection without pus or exudates bilaterally, prominent papillae of his tongue with redness as well as redness of his hands, and feet. He also has a new non-diffuse maculopapular rash on his torso that gets worse with fever. On examination of the swollen extremities, you are unable to elicit any tenderness or effusions in any joints. Which of the following is the most likely diagnosis? A Rocky Mountain Spotted Fever (RMSF) B Bone or joint infection C Kawasaki disease (KD) D Scarlet fever E Systemic onset juvenile idiopathic arthritis

A. Rocky Mountain Spotted Fever (RMSF) is a tick-borne disease caused by Rickettsia rickettsii. (SE parts of U.S). Get: headache, fever, myalgia, and a centrally progressing petechial rash originating on the wrists and ankles. The maculopapular rash, and constellation of other symptoms, as well as lack of any recent travel history, makes this diagnosis less likely in this patient. B. Bone or joint infection should be on the differential given the patient's refusal to walk, as up to 80% of these infections are in the lower extremities. The fever associated with septic arthritis and osteomyelitis typically are not as elevated as the one presented in this case, and the lack of localized symptoms of warmth and tenderness associated with the lower extremity erythema and swelling make this diagnosis somewhat less likely in this patient. C. CORRECT Kawasaki disease (KD) is one of the most common vasculitides of childhood. For diagnosis, in addition to fever of > 5 days, patient must meet four of the following criteria: rash, conjunctivitis, unilateral cervical lymphadenopathy, changes in oral mucosa, or extremity changes (redness/swelling). Our patient does not have lymphadenopathy, but often this is the least common finding in KD. If children have fever with fewer than four of the five clinical findings, they can have "incomplete KD" if they meet certain laboratory criteria. D. Scarlet fever is caused by erythrogenic toxin produced by Streptococcus pyogenes. Get sore throat, fever, "strawberry tongue" and a blanching, erythematous rash with desquamation of the affected areas about six to seven days later as the rash begins to disappear. While our patient does have a "strawberry tongue," fever, and rash, the description of the rash and other physical exam findings are more consistent with KD than with scarlet fever. E. Systemic onset juvenile idiopathic arthritis, also known as Still's disease, is a subset of JIA describing patients with intermittent rash, fever and arthritis. While our patient does present with rash and fever, as well as refusal to walk (potentially a sign of arthritis), systemic onset JIA tends to present with a history of spiking fevers and "salmon" rash occurring when the child is febrile, and disappearing as the fever fades. This is inconsistent with the description of the findings seen in our patient, who does not demonstrate tenderness or effusion in any joint.

An 11-month-old boy is brought to the ED by ambulance. His father called 911 after the patient's eyes deviated to the left as his arms and legs were twitching. During this time he was unresponsive. He has had a tactile fever for three days, and parents mention that he has not been as playful as usual during this time as well. His parents have not had him vaccinated due to personal beliefs. In the ED his vital signs are T 39.1°C, HR 155 bpm, RR 28 bpm, BP 100/65 mmHg, O2 100% (on RA). He does not cry but whimpers during most of your physical exam (including when you look in his ears). You order a CBC and metabolic panel, which are significant for a leukocytosis with a left shift and mild acidosis. Urinalysis and blood/urine cultures are pending. Which of the following additional studies would you obtain? A Chest x-ray B Toxicology screen C Lumbar puncture D Electroencephalogram (EEG)

A. The history given is not suggestive of any pathologic lung process occurring in this patient (no cough, respiratory distress, or desaturation). While it is possible that pneumonia could be causing his fever, a chest x-ray is not indicated at this time. B. It is important to consider toxin ingestion in a patient with altered level of consciousness and seizure. Most toxicology screens, however, are limited to drugs of abuse and may not detect many of the toxins that children commonly ingest. Furthermore, this patient's fever and leukocytosis make infection a much more likely diagnosis. C. In a young child with fever and altered level of consciousness we should always have a high suspicion for meningitis. This patient's parents expressed concerns about his behavior at home before his seizure, and his mental status during your examination is not normal. While very few patients presenting with febrile seizure actually have meningitis, this patient's lack of immunizations put him at increased risk. Furthermore, clinical signs of meningitis in patients under 12 months of age can be very subtle, and so a high level of suspicion is important. A lumbar puncture will help rule in or out meningitis and guide treatment. Note that in some cases the clinician will request a head CT prior to performing a lumbar puncture if there are concerns about increased intracranial pressure. A head CT in itself may not be helpful in the evaluation of a patient with a seizure, although it may be useful in cases where trauma is suspected, or to look for calcifications (such as with cytomegalovirus infection or tuberous sclerosis). D. For children with focal, recurrent, or complex seizures, an EEG to establish a diagnosis of epilepsy. Sixty percent of children and infants may have an interictal epileptiform abnormality. In this case it will not help to guide management acutely.

Rosy is an 18-month-old previously healthy baby girl who presents to clinic with congestion for three days. Today, her vitals are: T 101.2°F, BP 100/60 mmHg, P 80 bpm, RR 28 bpm. On physical exam, Rosy has clear mucus coming from both nostrils. Both turbinates show erythema. Her oropharynx is erythematous. No crackles or wheezing are heard. Mom reports that acetaminophen aids in bringing down the fever temporarily; however, the fever returns in a few hours. Mom is concerned for possible pneumonia since she was recently was given antibiotics for bronchitis. Her immunizations are up to date. Which of the following is most likely responsible for Rosy's symptoms? A Strep pneumoniae B Group A Strep C Rhinovirus D Hemophilus Influenzae type B E Pertussis

A. Rosy's symptoms do not fit a diagnosis of pneumonia, as she does not have significant fever, increased respiratory rate, crackles, or rales. B. Group A Strep is rarely a cause of pharyngitis in young children and notably does not cause feared sequelae (rheumatic fever) in those < 3 years. ****C. Rhinovirus causes common cold and is the most reasonable diagnosis. Rhinovirus is a very common cause of congestion and other cold-like symptoms. Rosy presents with slightly elevated temperature, slight tachypnea, and inflamed turbinates and oral mucosa. Her symptoms all correlate with the common cold. D. Hemophilus Influenzae type B causes pneumonia and epiglottitis. E. The catarrhal phase of pertussis can be indistinguishable from common cold, but quickly develops into paroxysmal phase. The paroxysmal phase is characterized by coughing fits and post-tussive emesis, which again Rosy does not have. It typically does not have associated fever.

A 5-month-old male presents to urgent care with his mother who states that she witnessed her son stop breathing and turn blue for about 25 seconds. Upon physical stimulation by the mother, patient began to breathe again. This is the first time she has ever witnessed this happening. The patient's birth and past medical history are unremarkable. Physical exam is unremarkable, vital signs are stable and normal, and lab studies are all within normal limits. Which of the following is LEAST likely to be on the differential diagnosis as a cause for this patient's ALTE (apparent life threatening event)? A Seizures B Arrhythmia C Infection D Gastroesophageal reflux E Congenital heart disease

A. Seizures are a relatively common cause of ALTE. T(15 to 20% of infants). In a patient with a suspected sz, the patient may have displayed some or all of following during symptoms: foaming at the mouth, loss of bowel or bladder incontinence, abnormal posturing, abnormal ocular eye movements, and/or biting of the tongue. However, some seizures may not display any of these symptoms. An EEG may be useful in evaluation of seizures in a patient presenting with an ALTE. The causes of seizures are vast and include the following: intracranial bleeds, CNS infections, metabolic abnormalities, electrolyte abnormalities, fevers, genetic syndromes and structural abnormalities. B. up to 5% of ALTEs have been shown to be caused by cardiac arrhythmias. Particular arrhythmias may include prolonged QT syndrome, Wolff-Parkinson-White, or bradycardia secondary to congenital heart block. In patients born to mothers with lupus, the suspicion for congenital heart block as a cause of the ALTE should be high. An EKG would be very useful in evaluation of this patient's ALTE. C. infectious etiologies are a common cause of ALTE, particularly infection with RSV or B. pertussis. A viral respiratory tract infection can also be associated with increased risk for reoccurrence of an ALTE. Patients with infections or sepsis may present with apnea, pallor, tachycardia, fever or hypothermia. They often have poor oral intake and their muscular tone is frequently diminished. In children less than 1 month of age, common etiologies of infection include Group B strep, E. coli, Streptococcus pneumoniae, listeria, and HSV. A CBC, respiratory virus PCR panel, CXR, and possible blood cultures would be helpful in evaluation of this patient's ALTE. D. GER is diagnosed in up to 30% of patient's presenting with an ALTE. However, there has never actually been a demonstrated link between reflux and apnea. It is thought that reflux triggers laryngospasm, but tx of reflux does not necessarily prevent reoccurrence of the ALTE. Reflux as a cause of ALTE is more likely when the infant has gross emesis or regurgitation during the ALTE. If this patient does have gastroesophageal reflux, he may benefit from a therapeutic trial of H2 blocker. He may also benefit from instituting reflux precautions after meals such as leaving the patient upright for 15 to 30 minutes after eating, making sure the baby burps after eating, and tilting the crib up to 30 degrees in the downward direction when the baby sleeps. **** Choice E is correct because it is unlikely for a patient with congenital heart disease to first present with an ALTE. This patient has no past medical history and his birth history was unremarkable. Typically the patient will suffer from acute decompensation within the first few weeks of life. These patients will also have growth problems, difficulty with feeding and a murmur is often appreciated on physical exam. Children with undiagnosed Tetraology of Fallot may have intermittent episodes of cyanosis while blood supply is diverted from the pulmonary vasculature.

A 3-year-old female is at the pediatrician's office for continued right knee pain after a ground-level fall six weeks ago. The patient is UTD on all immunizations, has no significant PMH, and no recent illnesses. Mom reports the patient complains of pain mostly in the morning when going to daycare but doesn't seem to be bothered by it while playing outside in the afternoon. On exam the patient's vitals are all within normal limits. Her physical exam reveals a well-appearing toddler who walks stiffly and avoids bending her right knee. The knee has a mild effusion but no obvious erythema. There is pain with passive flexion and extension of the right knee. During the exam the girl tells you her left ankle also hurts, which mom had forgotten about but says started hurting the same time as the right knee. Her CBC is normal, while her ESR and CRP are mildly elevated. Which of the following is the most likely cause of this patient's condition? A Septic arthritis B Leukemia C Juvenile idiopathic arthritis D Transient synovitis of the hip E Bacterial osteomyelitis

A. Septic arthritis is incorrect. Patients with septic arthritis are often febrile. Joint fluid analysis often reveals elevated WBCs and predominant neutrophils (although a joint tap in this scenario is not necessary based on the presenting symptoms and exam). Bacteria may also be cultured from the joint fluid. One would expect to see a greater elevation of markers of inflammation in septic arthritis. B. Leukemia is incorrect because patient does not present with other systemic symptoms such as fever, weight loss, lymphadenopathy, hepatosplenomegaly, petechiae, or bruising. Additionally, a normal CBC without thrombocytopenia or anemia makes this answer unlikely. ****C. Juvenile idopathic arthritis (JIA) is correct for several reasons. Pauciarticular juvenile arthritis is the most common type of JIA (60% of JIA) and causes pain in four or fewer joints for six or more weeks. This patient is generally well even after six weeks of pain, which would be unlikely if this patient had septic arthritis. Her pain improves with activity, and the ESR/CRP are only mildly elevated. On exam, she has a mild effusion but no obvious erythema. In cases of systemic JIA, patients may have a rash which lasts only a few hours (evanescent) that is also macular and salmon, and high-spiking and appears periodically (once or twice a day); however, this form of JIA is not consistent with this patient's history. D. Transient synovitis of the hip is incorrect because this condition. Generally resolves in 3-4 days and this patient has had pain for six weeks. Transient synovitis typically affects the hip, but patients may also report knee or inner thigh pain. Commonly, patients may have a history of a recent URI. Additionally, patients with transient synovitis do not typically present with a joint effusion as is seen in this patient. E. Bacterial osteomyelitis in children, usually hematogenous in origin, presents with acute onset of bone pain and fever and may involve a contiguous joint. This patient is well appearing and has no leg tenderness.

An 18-month-old female is brought to her pediatrician by her mother who notes that she has been has been fussy for the past three days and has been pulling on her ears. The child is up to date with her hepatitis B, rotavirus, DTaP, H. influenza type B, pneumococcus, and polio vaccines. Her temperature is 102.2 F. Otoscopic exam of her left ear shows a yellow, opaque, and bulging tympanic membrane. Which of the following organisms is the most likely cause of the child's condition? A Streptococcus pyogenes B Candida albicans C Haemophilus influenzae D Rhinovirus E Moraxella catarrhalis

A. The child is suffering from acute otitis media (AOM). S. pyogenes is a rare cause of this condition (< 5% of cases). One should not confuse this species of strep with S. pneumoniae, which is a common cause of AOM (25-50% of cases). B. Candida albicans is not a frequent cause of AOM. An infection involving this organism in the middle ear should immediately raise suspicion for an immunocompromised state. ****C. H. influenzae is a frequent cause of AOM (15-52% of cases). Although the child has been vaccinated against H. influenzae type B, this does not cover the unencapsulated strains of H. influenzae that cause AOM. D. Rhinovirus is a potential cause of AOM, but bacterial AOM occurs with a much higher frequency. E. M. catarrhalis is another common cause of AOM. However, this organism is responsible for only between 3% and 20% of cases, making it a less frequent cause than non-typeable H. influenzae.

A 15-month-old boy presents to the ED in January with a 3-day history of diarrhea. His current weight is 11 kg. He was born at 39 weeks, without any perinatal complications. There is no significant history of travel, sick contacts, or recent changes in diet. The mother notes that he has had only 2 diaper changes over the last day. Physical exam is remarkable for an irritable but consolable infant with tachycardia and normal blood pressure. He is crying without tears and his mucous membranes are dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds. He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the following statements is true? A The patient is mildly dehydrated and should be managed with oral rehydration (Pedialyte). B The patient is moderately dehydrated and should be managed with oral rehydration (Gatorade). C The patient should be rehydrated with clear liquids and then transitioned to a lactose-free diet until his diarrhea resolves. D The patient is moderately dehydrated and should be bolused with 220 ccs of D5 ½ normal saline for emergency phase correction, to ensure hemodynamic stability. E The work-up for infectious diarrhea for this patient should include a Wright's stain for fecal WBCs, a stool Rotazyme, and a stool sample for culture and sensitivity.

A. The patient is likely moderately dehydrated, given minimal urine output over last day, tachycardia (in face of normal blood pressure), and preserved skin turgor and capillary refill. If patient was mildly dehydrated, oral rehydration therapy would be appropriate management, and in low resource settings, oral rehydration has been used very successfully for moderately dehydrated children as well. B. Gatorade would not be recommended as a rehydrating solution for a 15-month-old child. The sugar concentration is high and this may lead to an osmotic diarrhea. C. Current recommendations from the American Academy of Pediatrics suggest reintroduction of the regular diet, as tolerated, and not transitioning first with a lactose-free diet. D. Moderately dehydrated patients should be bolused with 20 ccs/kg of IV fluid to insure hemodynamic stability and adequate perfusion of vital organs. The preferred fluids would be normal saline or lactated ringers. ****E. In addition to correcting this patient's hydration status, a work-up for the infectious causes of this patient's diarrhea might include a stool Wright's stain for fecal WBCs (which would suggest a bacterial cause if this is infectious diarrhea), a Rotazyme test (given high incidence of rotavirus in winter months), and a stool sample for culture and sensitivity. Additional studies might include stool guaiac (for occult blood) and a check for stool C. diff toxin.

A 16-year-old homeless female presents with low-grade fever and abdominal pain. The patient reports recent unprotected sex. Abdominal examination reveals tenderness to palpation in the lower abdominal region, but no masses are appreciated. Pelvic examination reveals whitish cervical discharge and cervical motion tenderness. The discharge is sent for culture, and a pregnancy test is negative. What is the next best step in management? A Pelvic ultrasound B Begin oral antibiotics antibiotics and treat her partner C Arrange for hospitalization D Abdominal CT E Surgical consult

A. This choice is incorrect. Although pelvic ultrasound is helpful in identifying pelvic disease processes, this patient has signs and symptoms of pelvic inflammatory disease (PID). Treatment of PID can be initiated without further diagnostic workup. B. This choice is incorrect. Although most patients with PID can be discharged home with home antibiotics, this patient is homeless and is therefore at higher risk for failure to complete a coures of antibiotics. *****C. This choice is correct. This patient has signs and symptoms of PID. Cervical discharge should be tested for gonorrhea and chlamydia and sent for culture. As she is a homeless patient, she is at high risk for failure to complete her antibiotic course. Given deleterious sequelae of incompletely treated PID, she should be hospitalized in order to ensure a full course of treatment. D. This choice is incorrect. Abdominal CT is not helpful in diagnosing PID. An argument could be made for US if ovarian torsions were suspected, or if her sxs were refractory to treatment, suggesting a tubo-ovarian abscess that could be detected by ultrasound. E. This choice is incorrect. Although the patient exhibits abdominal pain, further workup is required before calling a surgical consult. As the pregnancy test is negative, a ruptured ectopic pregnancy is not an acute concern at this time.

A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would be characteristic of the cough that this patient would present with? A Does not awaken patient from sleep B Paroxysmal C Barking cough D Worse at night E Associated with crackles on exam

A. This choice is incorrect. Habitual cough disappears at night. B. This choice is incorrect. Paroxysmal coughs are associated with bacterial infections such as pertussis, Chlamydia, or mycoplasma. Foreign bodies can also produce sudden onset of cough. C. This choice is incorrect. Barking coughs are associated with croup or other forms of subglottic disease. Foreign bodies can also produce this type of cough. ****D. This choice is correct. Asthma frequently presents with nighttime exacerbations. The cough often presents with wheezing and is usually a dry cough. E. This choice is incorrect. Diseases associated with crackles usually have intrinsic pulmonary involvement. Crackles can be fine or coarse and usually represent alveolar or small airway conditions.

A 3-year-old boy described by his mother as a picky eater comes in for a regularly scheduled well-child visit. His mother complains that he has had less energy than usual for the past few months. There is a high clinical suspicion he is anemic. Which of the following is most correct? A The most cost-effective test to diagnose anemia is a CBC. B Lead screening is never warranted since a 3-year-old is usually not mouthing objects. C The most likely cause of anemia in the question is picky eating resulting in low iron intake, which would cause microcytic anemia. D The most common cause of anemia in this situation is folate deficiency. E If anemia is due to poor nutrition, restarting the bottle will help the child recover the most.

A. This choice is incorrect. The most cost-effective method to diagnose anemia is a screening hemoglobin. B. This choice is incorrect. Although most 3-year-olds stop mouthing objects, they may have been exposed to lead in the past but were not symptomatic at the time. C. This is the correct choice. The most likely cause of anemia in the question is picky eating, which can result in insufficient iron intake. Low iron intake causes a microcytic anemia. A girl with menometrorrhagia would present with iron deficiency, and her MCV also would be indicative of microcytic anemia. D. This choice is incorrect. Iron deficiency is the most common cause of anemia in this scenario. Note that folate deficiency may be associated with a goat's milk diet. E. This choice is incorrect. It is best to stop the bottle by age one year. Solid foods provide more complete nutrition, including iron. An additional concern of prolonged bottle usage is the development of dental caries.

A 16-year-old previously healthy male comes to the Pediatrics Urgent Care Clinic having "almost fainted" at soccer practice. He says that he had not eaten much earlier in the day and it was very hot and muggy outside. He felt light-headed and sick to his stomach. He denies losing consciousness and did not fall to the ground. He denies any chest pain. When you examine him, his eyes are sunken and he is tachycardic. What would be your next step in his management? A Electrocardiogram (ECG) B Measure his blood glucose C Echocardiogram D Give fluids and recheck his vital signs E Stress test

A. This choice is incorrect. While an EKG would be useful to assess for possible arrhythmia (long QT syndrome, WPW) or hypertrophic cardiomyopathy, the patient did not have a syncopal event or chest pain. As a result, an EKG would not be the most appropriate next step in diagnosis. B. This choice is incorrect. While the patient has had poor PO intake, hypoglycemia is relatively uncommon in an otherwise healthy young male. In addition, we would expect symptoms including diaphoresis, anxiety, and tremulousness, as opposed to dizziness. C. This choice is incorrect. Obstructive outlet pathology is less likely given the presentation, as no syncopal episode occurred. An echocardiogram may be indicated, but it would not be the next step in the evaluation. ****D. This choice is correct. The patient is likely dehydrated given the dizziness without loss of consciousness in the setting of poor PO intake, hot weather and exercise. As the symptoms occurred while he was upright, the likely mechanism is vasovagal. His sunken eyes and tachycardia are signs of moderate to severe dehydration. Since this is a clinical diagnosis, fluids should be given with subsequent rechecking of heart rate and blood pressure to confirm the diagnosis. E. This choice is incorrect. A cardiac etiology like hypertrophic cardiomyopathy is less likely given the presentation, and a stress test would not be the next step in the evaluation.

A 3-year-old child is found to have a dry, pruritic rash on his face. PE is notable for confluent areas of erythema and scaling. There are mild excoriations surrounding some areas and mild lichenification of extensor surfaces of both elbows. What is the next best step in management of this child's problem? A Oral clindamycin for 5 days B Changing detergents C Topical clotrimazole D Topical steroids and emollients E 5% permethrin cream

A. Treatment with clindamycin would be appropriate for tx of cellulitis due to MRSA. The rash described is not consistent with cellulitis. B. Changing detergents would be an appropriate intervention for irritant dermatitis. The fact that the child has lichenification on the extensor surfaces argues against this diagnosis. Irritant contact dermatitis is often found in the diaper area, face, and extensor surfaces on children secondary to irritating substances. It is typically less pruritic than atopic dermatitis. C. Tx with topical clotrimazole would be appropriate for tinea corporis. However, the rash described in this vignette is not consistent with this diagnosis. ***D. Correct. Atopic dermatitis most often presents with dry, itchy skin in addition to erythema, scaling, vesicles, or lichenification in skin flexures. Treatment consists of emollients and topical corticosteroids. E. Treatment with permethrin cream would be appropriate for scabies infection.

You are working in the pediatric ED when a 3-year-old girl, Jenny, presents with altered mental status for the past six hours. Her mother reports that the babysitter called her at work today after Jenny started acting agitated and "looking very sick." The mother reports "she feels so warm, I think she has a fever and has become dehydrated." On exam, the patient is agitated and anxious with dilated pupils. Her skin is warm and dry. Vitals reveal tachycardia and hypotension. You suspect the child may have accidentally ingested one of her mother's medications. An overdose of which of the following medications could cause Jenny's symptoms? A Tricyclic antidepressant B SSRI C Decongestant D Acetaminophen E ACE inhibitor

A. Tricyclic antidepressant (TCA) is correct. TCA toxicity presents with agitation, tachycardia, hypotension, dilated pupils, and hot, dry skin from the anticholinergic effects of TCAs. B. SSRI is incorrect, because serotonin syndrome will usually present with a fever and sweaty, not dry, skin. Also, serotonin syndrome usually does not present with hypotension. C. Decongestant is not the correct answer. Decongestant overdose will elicit a sympathomimetic response, including agitation and tachycardia. Will cause hypertension, constricted pupils, fever/sweating. Additionally, severe overdose of decongestant may cause seizures. D. Acetaminophen is not the correct answer. Acetominophen overdose will produce mild and nonspecific symptoms and include right upper quadrant pain, with elevation in liver enzymes, resulting in liver failure at toxic levels. E. ACE inhibitor is not the correct answer. The typical adverse event for ACE inhibitors is cough.

On your first day rotating in the pediatric clinics, you are assigned to see a patient who is 9 weeks old and was brought into clinic by his worried mother. She states that her son has not gained weight since they left hospital. His weight is < 5th percentile, and height and head circumference are at the 25th percentile. His mother says he drinks two ounces of milk every two to three hours, and suckling is strong without any spitting up during feeds. He poops more than 10 times a day, but it appears greasy and foul smelling. He had an unremarkable birth history and a normal newborn screen. Cardiac, pulmonary, abdominal, and neurologic exams are all normal. His mother mentions her cousin had trouble gaining weight and would get frequent "lung infections." Which of the following is the best next step in management? A Increase formula to a higher calorie mixture B Stool culture and Wright stain C Swallow study D Sweat chloride test E Echocardiogram

A. Two ounces of milk every two to three hours is adequate intake. This child may need a higher calorie formula in the future, but not before a diagnosis has been made, as there is likely an organic cause of failure to thrive. B. Stool culture with Wright stain for WBC's could be useful in a patient with diarrhea if you suspect an infectious cause of the diarrhea. This patient however, presents with no fever and no blood in the stool, and a good appetite, all of which are less consistent with an infectious etiology. C. A swallow study would be used to evaluate this child's ability to drink fluids, but since he has not been spitting up and appears to take in milk without difficulty, this test would be less useful at this time. ****D. The patient's greasy and foul-smelling stool is characteristic of steatorrhea, or fat in the stool. This occurs in patients with cystic fibrosis due to impaired pancreatic exocrine function. Given stool history in face of ftt, a sweat chloride test would be indicated at this time. Of note, family history of poor weight gain in a cousin with frequent lung infections also suggests the possibility of cystic fibrosis-related bronchiectasis. Cystic fibrosis should still be suspected in child who has a normal newborn screen. States differ in the type of test offered to screen for cystic fibrosis, and although great strides have been made in newborn detection, methods are not 100% sensitive. E. An echocardiogram may be useful if you suspect congestive heart failure as the cause of failure to thrive. In this case, however, the cardiac exam was normal and there were no other signs of heart failure, such as tachypnea, tachycardia, hepatomegaly, lower extremity edema, or crackles on lung exam.

An 18-year-old mother with her 3-month-old son arrives at urgent care clinic with a chief complaint of "my baby stopped breathing!" She and her baby are rushed into a triage room, where her son is noted to be very lethargic with increased work of breathing. As vital signs are being obtained, the mother reports "my baby stopped breathing in the car coming here, and didn't start again until I reached over and jostled his car seat!" Mom then shared that "my boyfriend said he rolled off the couch last night. Could it be related?" Mom also stated that her son hasn't been as active as usual, and has been vomiting occasionally. Physical exam is notable for a respiratory rate of 70 bpm with intercostal retractions and crackles in right lower lung fields posteriorly. You admit this patient with the diagnosis of pneumonia for empiric antibiotics and support, pending additional evaluation. CXR subsequently demonstrates a RLL infiltrate and faint, vertical lines on several posterior ribs bilaterally. What is the best next step in management? A Obtain a PTH level B Sweat chloride testing C Skeletal survey (more x-rays) D Anticipatory guidance about appropriate car seat usage E Head ultrasound

A. While there is certainly the possibility of increased risk of fracture in infants who have with primary hyperparathyroidism, this is an extremely rare disorder. While it may lead to skeletal demineralization, this would more likely be seen on x-ray as decreased bone density. Importantly, this pattern of posterior rib fractures, which may be caused by squeezing the infant's thorax, should lead the clinician to suspect abuse. ***C. In this case a skeletal survey is essential. Posterior rib fractures are always concerning findings. While treatment of the patient's pneumonia has been initiated, a complete skeletal survey will screen for other worrisome findings, including multiple fractures in different stages of healing, fracture of the femur or tibia in a non-walking child, and skull fractures. D. It is true that this mother needs to be better informed about car seat use, because the infant car seat should never be in the front seat of a car. This needs to occur prior to discharge, but does not have the same urgency as (C) above. E. Although head trauma (from falling from the couch) could result in an intracranial bleed and lethargy, the best test for such a bleed and/or skull fracture would be a CT scan, not an ultrasound.

A 6-month-old female with normal birth and developmental history presents with fever for the past two days, fussiness, and decreased appetite. ROS is negative. No abnormalities are noted on the physical examination. A urinalysis from a bag specimen is positive for leukocytes and nitrite, which suggests the presence of a UTI; a culture from this sample is pending. The patient is ill-appearing, dehydrated, and unable to retain oral intake. She is hospitalized, receives a 20 cc/kg NS bolus and is placed on maintenance IV fluids with clinical improvement. What is the best next step for management of this patient? A Urinary catheterization B Renal bladder ultrasound C Begin parenteral antimicrobials D Midstream clean catch urine collection E Increase IVF administration rate to flush the kidneys

A. Urinary catheterization is correct . It is the best method for obtaining a specimen for culture that has not been contaminated by perineal bacteria, and for this ill child, you must determine the cause of the fever with accuracy. B. Renal ultrasound may be indicated if the infant is found to have a urinary tract infection but is not indicated as part of the initial work up. C. With a bag culture pending, you may have a contaminated/confusing culture result and may have to rely solely on clinical criteria to treat this presumed UTI. D. Midstream clean catch specimen is incorrect because it is not ideal in a patient who has not been toilet-trained and cannot void on demand. E. While it is important to provide hydration, this patient has responded well to the initial fluid administration, and there is no evidence that increasing this beyond normal recommendations is helpful.

Devin is a 2-year-old African-American boy with sickle cell disease. Today his parents brought him to the ED because he was not feeling well. His mother reports that he has been very tired for the past week. Vitals show a temperature of 39°C, BP of 120/75 mmHg, RR of 24 bpm, and HR of 104 bpm. On physical examination he is ill appearing. His conjunctivae appear pale, and his sclerae are anicteric. Lungs are clear to auscultation. His abdominal exam is benign (non-tender, non-distended, with no organomegaly). His extremities are non-tender upon palpation. His nailbeds appear pale. Stat CBC reveals Hgb: 4.5 g/dL, Hct 15%, WBC 1800, and platelets 88,000. Mother is concerned as she has never seen him so ill before. What is the most likely cause of his new symptoms? A Vaso-occlusive crisis B Splenic sequestration C Aplastic anemia D Hemolytic crisis E Chest crisis

A. Vaso-occlusive crisis would likely present with pain, and is not usually associated with a decrease in all cell lines as seen in this child's CBC. B. Splenic sequestration could potentially cause thrombocytopenia and anemia in a sickle-cell patient; however, there is no organomegaly noted on exam, and it does not explain his fever. ***C. Parvovirus B19 causes aplastic anemia, especially in children with shortened RBC half-life. A mild anemia associated with parvovirus often goes unnoticed in healthy children. However, in patients with decreased RBC survival, such as sickle-cell patients, anemia can develop very rapidly and severely, along with decreases in the other cell lines (resulting in leukopenia and thrombocytopenia). In the above presentation, the presence of fever in a child with sickle cell disease should also raise concern for significant bacterial infection from encapsulated organisms like pneumococcus. This patient should have a blood culture and be started on empiric antimicrobial therapy pending screen labs and cultures. D. Hemolytic crisis is unlikely as patient's sclera are anicteric, and thus he is probably not hemolyzing significantly. Hemolysis would also not explain his leukopenia or thrombocytopenia. E. Chest crisis should be considered in all sickle cell patients who present with chest pain, increased work of breathing, or infiltrates on chest x-ray, which may be consistent with either infection or infarction. The patient had no pulmonary symptoms, and the CBC findings are not consistent with chest crisis.

A 7-year-old girl is brought to her pediatrician because of recurrent puffy eyes. She presented one week ago because of the same problem and was diagnosed with allergies. She was started on an intranasal steroid with no relief. Her mother states she has become increasingly tired and mentions that she has recently outgrown all of her shoes. The patient has no other symptoms and is at the 50th percentile for height and weight, is afebrile, and non-toxic appearing. Her heart and lung exam are normal. She has no hepatomegaly and no evidence of rash. What is your next step in diagnosis/management? A Echocardiogram B Urinalysis C Flonase trial for an additional week D CBC with manual differential E Liver enzymes

A. While CHF may present as edema, this patient has no complaints of respiratory symptoms or associated findings on physical exam (such as crackles or a murmur). An echocardiogram would not be the next step in diagnosis, even if CHF is expected. ***B. Because of high suspicion of nephrotic syndrome, a UA would be next step in diagnosis. This patient has symptoms of periorbital edema, lethargy, and pedal edema Nephrotic syndrome is defined as proteinuria > 50mg/kg. However, cannot be detected with a UA. A UA dipstick will show high albumin concentration (graded as 3+ or 4+), and is used as a screening tool. Additional testing will be needed to confirm the diagnosis. C. Nephrotic syndrome is often misdiagnosed as allergies. D. While a CBC may show an increased hemoglobin and hematocrit secondary to volume depletion and thrombocytosis, it is not a test that will diagnose nephrotic syndrome. However, if the patient presented with edema and was febrile, a CBC may be warranted to rule out sepsis. E. patient does not appear jaundiced and does not have hepatosplenomegaly.

A 4-year-old male with a history of Down syndrome and no other medical problems is brought to his pediatrician's office by his mother for increasing fatigue, intermittent fever, and decreased appetite for one week. On exam you note conjunctival pallor and hepatosplenomegaly. What is best next step in the management of this patient? A Advise the mother to use acetaminophen as needed for fever and discharge home with strict return precautions. B Send CBC and peripheral smear C Send patient for chest x-ray D Send TSH E Start the patient on a 7-day course of amoxicillin and send home with strict return precautions.

A. patient is likely presenting with signs and symptoms of acute leukemia in a patient at increased risk for childhood malignancy (specifically ALL). ***B. This choice is correct because fatigue, decreased appetite, anemia, and HSM are all clinical signs and symptoms that may be associated with acute leukemia, for which patients with Down syndrome are at increased risk. C. patient is not presenting with any acute respiratory symptoms to warrant immediate chest x-ray.

A 10-year-old boy presents to his pediatrician with a history of hypopigmented non-pruritic "dots," mostly located on his face and neck. His mother complains that lesions get worse during the summer when her son plays outside. On exam, they are slightly scaly, hypopigmented lesions approximately 0.5 cm in diameter. What is the most likely etiology of his rash? A A pox virus B Hyperproliferation of keratinocytes C S. pyogenes and S. aureus D Decreased number of active melanocytes and decreased number and size of melanosomes E Ingrown hairs with resultant inflammation

A. pox virus is the cause of molluscum contagiosum. Lesions are dome-shaped, firm, and often with a central indentation. They can appear anywhere on the body, but spare palms and soles. B. hyperproliferation of keratinocytes is characteristic of psoriasis. Psoriasis can present in a variety of ways, but most commonly presents as a plaque. Plaques are often located on scalp, external ear, and extensor surfaces presenting as a thick silvery scale and sharply demarcated borders. It may or may not be pruritic. C. Staphylococcus aureus and Streptococcus pyogenes cause cellulitis. It is most often "non-bullous" but may also present as "bullous impetigo" or "ecthyma." They may start as papules and then become inflamed vesicles, progressing to pustules with a "honey-colored" crust. Lesions often appear near the nose because of rubbing. ****D. Pityriasis alba, common in children 3 to 16 years of age, presents as hypopigmented macules. They most often occur on face, neck, trunk, and extremities. They have irregular borders, can vary in size, and may have a slight scale. Lesions may become more noticeable after sun exposure because of tanning of the surrounding skin. The etiology of this disorder is unknown, but ultrastructural examination of epidermal cells reveal decreased number of active melanocytes as well as decreased number and size of melanosomes. E. Pseudofolliculitis occurs as papules normally located in the beard or hair distribution. It appears similar to acne, but it is more closely located to hair follicles. Development of this disorder is related to trauma due to shaving or plucking.

normocytic anemia differential

Acute blood loss Immune hemolytic anemia Hereditary spherocytosis G6PD deficiency Sickle cell anemia Renal disease Transient erythroblastopenia of childhood (TEC)

Aspirin OD

Agitation Tachycardia NO mydriasis.

Factors that cause obstruction of the sinuses (5)

Allergies Viral upper respiratory infections (URIs) Trauma Nasal polyps Thickened secretions from cystic fibrosis

Systolic ejection murmur

Aortic and pulmonic valve stenosis.

Adverse effects of ADHD medications

Appetite suppression Insomnia Decrease in growth velocity

Best prognosis of all infratentorial tumors in child

Astrocytoma of cerebellum

ADHD dx

At least 6 sxs in realm of inattention, hyperactivity and impulsivity

A 9-year-old male is brought to the ED in a coma secondary to diabetic ketoacidosis. Which of the following laboratory results would NOT likely be found in this patient? A Anion gap of 20 mEq/L B Potassium of 3.3 mEq/L C Venous pH of 7.1 D Sodium of 132 mEq/L E Creatinine of 1.0 mEq/L

B

The mother of a 5-year-old boy calls your office asking if she should take her son to the emergency room or wait another day. She states that her son suddenly developed a "high fever" and is extremely tired. When you ask about her son's behavior, she states that he also seems very confused. She also noticed he had developed reddish-purplish spots on his extremities. What is the next best step in management of this patient? A Have the patient make an appointment to come to your office today B Tell the mother to take her son to an ED immediately C Have the patient hydrate well over the weekend and follow up with you in a few days D This patient most likely ingested something. Recommend ipecac to induce emesis and call 911

B has been selected by the expert. A. Choice A is incorrect because any acutely altered mental status should raise serious concern, and therefore an office visit would probably not be adequate. B. Choice B is correct. This patient is exhibiting signs of sepsis, more specifically, of meningococcemia. Although it is important to replenish this patient's fluids and control his fever, it should not be done in an outpatient setting. This is a medical emergency! Sepsis can lead to altered mental status. Signs and symptoms of sepsis include: fever, nausea, vomiting, diarrhea, apnea/dyspnea, oliguria, pallor, tachypnea, tachycardia, lethargy, irritability, petechiae, purpura, tremors, and seizures. C. Choice C is incorrect. This patient is too ill to remain at home over the weekend with just supportive care. If he is bacteremic and septic he has a high mortality rate over the next 12 hours. D. Choice D is incorrect. There is no indication for inducing emesis, and this can present a risk of aspiration in a child with altered mental status.

A 16-year-old female presents to clinic complaining of worsening fatigue. Family history is significant for hypothyroidism and heavy periods in the grandmother. Her exam reveals mild tachycardia and oozing around a recent piercing, but is otherwise normal. Labs reveal Hgb 8.5 g/dL, MCV 58, PT 12.5, PTT 44, and low von Willebrand factor activity. Which of the following is the most appropriate treatment for her underlying disorder? A Blood transfusion and iron supplementation B Desmopressin C Factor VIII concentrate D Cryoprecipitate E Vitamin K

B has been selected by the expert. A. This patient has iron deficiency anemia, as indicated by her hemoglobin level and MCV. Nutritional deficiency is the most common cause of iron deficiency anemia, and in these cases iron supplementation would be appropriate. However, a blood transfusion and supplemental iron for a presumed nutritional deficiency without investigating potential ongoing losses is inappropriate, especially in a patient with oozing blood on exam. B. Von Willebrand's disease is the underlying cause of this patient's anemia, as indicated by the low von Willebrand factor activity. This is the most common hereditary bleeding disorder, occurring in roughly 1% of the population. Intranasal or intravenous desmopressin is appropriate treatment for most bleeding problems. Desmopressin works by causing release of von Willebrand's factor from vessel endothelial cells. C. Factor VIII concentrate may be used as a treatment for von Willebrand's disease in the setting of major trauma or surgery. It also may be used for less common subtypes of the disease that do not respond to desmopressin. However, most cases of von Willebrand's disease can be treated with desmopressin, and therefore it is the most appropriate first choice in treating this patient. D. Cryoprecipitate is a blood product containing fibrinogen, factor VIII, factor XIII, and von Willebrand factor. It is most commonly used to replace fibrinogen. It may also be used in certain scenarios for patients with von Willebrand's disease. However, it is not as good as desmopressin as a first choice in this scenario. E. Vitamin K is found in leafy green vegetables and in most multivitamins. It is important in the synthesis of clotting factors. It is given clinically as a one-time IM dose for neonates to assist in clotting factor formation until the gut microbiome is sufficient to provide Vitamin K. It is also used for patients who become supratherapeutic on warfarin therapy. It would not help in this case.

Adam is a newborn male who was just born to a G2P1 mother at 36.2 weeks' gestation via a vaginal delivery. The mother reports that she did not receive prenatal care because she did not have insurance. She says that she thinks her "water broke" about two days ago, but she did not have any contractions after that, so she decided not to come to the hospital. She did not start having contractions until 19 hours before she delivered. After delivery, Adam did not cry vigorously, was tachypneic, cyanotic, and febrile to 100.5 F. Amniotic fluid did not contain meconium. His chest x-ray is normal. Given Adam's birth history, what is the most likely cause of his symptoms? A Transient tachypnea of the newborn (TTN) B Sepsis secondary to prolonged rupture of membranes C Meconium aspiration syndrome D Hypothermia E Pneumothorax

B has been selected by the expert. A. Transient tachypnea of the newborn (TTN) is a benign, self-limited condition caused by delayed clearance of lung fluid after birth. Patients with TTN usually have a classic chest x-ray that shows coarse fluffy densities that represent fluid-filled alveoli and/or fluid in the pleural space and a small amount of fluid in the fissures on the lateral view. Given Adam's normal chest x-ray and fever, it is unlikely that Adam has TTN. B. Prolonged rupture of membranes (PROM) is when the chorioamniotic membrane ruptures before the onset of labor. The main risks associated with PROM are preterm labor and delivery and neonatal sepsis. Adam's mom said that her "water broke" two days ago, which indicates that she had PROM. Adam's mother also did not receive prenatal care; therefore, she did not receive any of the prenatal screening tests that she should have, which increases the likelihood that she has an infection that could have potentially been transferred to Adam after the rupture of her membranes. Adam's history of PROM along with his fever and respiratory distress make this answer choice the best choice. C. Meconium aspiration syndrome occurs when the baby passes meconium in utero and aspirates the meconium either in utero or at the time of delivery. Since it was noted that the amniotic fluid did not contain meconium, it is less likely that Adam is suffering from meconium aspiration syndrome, even though he has symptoms of respiratory distress that can often be seen in meconium aspiration syndrome. D. Hypothermia can cause tachypnea of the newborn, especially premature newborns. However, hypothermia is less likely in Adam given his fever of 100.5 F. E. Pneumothorax is less likely in this case because of Adam's normal chest x-ray, but is important to consider in a tachypneic newborn. The presence of Adam's fever also makes pneumothorax less likely to be the sole cause of his symptoms.

A 19-year-old G1P0 presents in labor to the ED at 38 gestational weeks. On interview it is discovered that the patient had irregular prenatal care, drank a couple of beers every weekend, and smoked 4 cigarettes a day. She delivers a baby boy who is small for gestational age. On exam, it is noted the baby has microcephaly, a smooth philtrum, and a thin upper lip. What do you suspect caused these features in the baby? A Tobacco exposure B Alcohol exposure C Congenital rubella D Vertically transmitted HIV E Congenital CMV infection

B has been selected by the expert. Fetal alcohol syndrome has very characteristic facial features, including a smooth philtrum, thinning of the upper lip, and small palpebral fissures. A. This choice is incorrect. While tobacco exposure can cause infants to be small for gestational age they typically do not have any characteristic facial features. C. This choice is incorrect. Congenital rubella presents with sensorineural deafness, eye abnormalities (retinopathy, cataracts), and patent ductus arteriosus. D. This choice is incorrect. Typically, vertically transmitted HIV does not lead to recognizable symptoms at birth. This diagnosis cannot be completely ruled out without lab testing. E. This choice is incorrect. Symptomatic congenital CMV infection presents with microcephaly, jaundice, hepatosplenomegaly, low birth weight, and petechiae at birth.

A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks' gestation. The newborn is noted to have dysmorphic cranial features and his head circumference is 28.5 cm (< 5th percentile). What is another associated abnormality you might expect to see in this newborn? A Hepatosplenomegaly B Cardiac defects C Absent red reflex D Chorioretinitis E Tremors

B has been selected by the expert. The mother was on an anticonvulsant for her seizures. Taking anticonvulsants during pregnancy may lead to cardiac defects, dysmorphic craniofacial features, hypoplastic nails and distal phalanges, IUGR, and microcephaly. Mental retardation may be seen. A rare neonatal side effect is methemoglobinuria. A. Hepatosplenomegaly: metabolic diseases, storage diseases, HIV vertical transmission, intrinsic liver disease, and in congenital infections. Maternal anticonvulsant use does not cause hepatosplenomegaly. C. An absent red reflex in a newborn can be due to congenital cataracts or a retinoblastoma. D. Chorioretinitis: congenital toxoplasmosis and CMV infections. Not caused by maternal anticonvulsant use. E. Tremors in a newborn can be due to maternal substance use. They would not result from maternal use of anticonvulsants.

A 4-day-old baby boy presents for his first pediatric well child visit. His birth history consists of an uncomplicated normal spontaneous vaginal delivery after 7 hours of labor—no vacuum or forceps assistance were used. The patient is the first child to a 30-year-old mother of Mediterranean descent. Mom is very concerned that her baby has started to look "yellow" since leaving the hospital. She has been breastfeeding every 2-3 hours and says that the baby latches on for 1-5 minutes for each feed. He has had few wet diapers, and mom is concerned he is not getting enough to eat. Which of the following would most aid in narrowing the differential diagnoses? A Newborn screen results B Fractionated bilirubin C WBC D Blood smear E No further workup is needed, as this is likely physiologic jaundice

B has been selected by the expert. The test that will give you the most information at this juncture is a fractionated bilirubin. With the knowledge of the total serum bilirubin (TSB) and direct serum bilirubin, one will be able not only to narrow the differential (hemolysis vs. obstruction), but also to guide treatment (i.e., indirect serum bilirubin may be above phototherapy level). TSB can also indicate if the situation requires more drastic measures, such as a transfusion exchange. A. The newborn screen result normally takes a few weeks to process. However, even if the results were available, they might suggest two possibilities in the differential diagnosis of jaundice: hypothyroidism or G6PD deficiency. Even though these diagnoses are important to rule out, the test would not provide more information about the infant's current state of health or the next step in treatment. C. A WBC could be helpful if the infant is at risk or showing signs of infection or sepsis. The child did not have a complicated birth history, and now has no signs of fever or distress. Although it may be helpful to check a CBC and know the hemoglobin level, in case of hemolysis, a WBC will not help narrow the differential as much as a fractionated bilirubin given the above presentation. D. A blood smear would be helpful to diagnose hemolysis or RBC membranopathies. However, a blood smear would not be the most useful in narrowing the wide range of possibilities in the current differential, because it would help with identifying hemolytic causes. At this juncture, a fractionated bilirubin would be the most useful test to order first. E. Although physiologic jaundice is the most likely cause of jaundice at this age for an infant, there is not yet enough information to rule out a more serious cause. Because the mother is of Mediterranean descent, it is very possible that the cause of jaundice is G6PD deficiency, so further workup is definitely necessary. At the very least, a fractionated bilirubin is needed, and then likely a CBC.

A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? A Sheets of lymphocytes with interspersed macrophages B Small round blue cells with dense nuclei forming small rosettes C Hypersegmented neutrophils D Stacks of RBCs E Enlarged cells with intranuclear inclusion bodies

B has been selected by the expert. This is the correct response. In addition to neuroblastoma, other tumors associated with small blue cells include Ewing's sarcoma and medulloblastoma, both of which tumors are seen in children. A. This is incorrect, as sheets of lymphocytes with interspersed macrophages are associated with Burkitt lymphoma. C. Hypersegmented neutrophils are characteristic of megaloblastic anemia, a condition associated with a vitamin B12 and/or folate deficiency, not malignancy. D. Stacks of RBCs suggest rouleaux formation, a phenomenon seen in multiple myeloma, a condition not seen in young infants. E. This describes the classic "owl's eyes" seen in CMV and other viral infections.

You are called down to the nursery to evaluate a newborn girl who is ready to be discharged. The mom is concerned because this 3-day-old has become lethargic and doesn't want to feed. She has vomited twice and is showing no interest in feeding. On physical exam you note a lethargic infant with an enlarged liver and worry about an inborn error of metabolism. Which test would be diagnostic for an ornithine transcarbamylase (OTC) deficiency? Please select one answer. A Hypoglycemia B Hyperammonemia and elevated urine orotic acid C Elevated 17-OH progesterone D Elevated TSH E Hyponatremia

B has been selected by the expert.Both hyperammonemia and elevated urine orotic acid are diagnostic of OTC deficiency, an x-linked condition, the most common urea cycle disorder. A. Although infants with an inborn error of metabolism may have hypoglycemia, it is not diagnostic of OTC. C. Elevated 17-OH progesterone would be expected and diagnostic of a patient with congenital adrenal hyperplasia (CAH) and would likely be associated with virilization in a female infant. D. Elevated TSH is diagnostic of congenital hypothyroism, not OTC. E. Infants with congenital adrenal hyperplasia may have low sodium, but not patients with OTC deficiency.

Intussiception in HSP

Because intussusception occurring in HSP is usually ileo-ileal, not ileo-colic, it will not be reduced by air or barium enema. Diagnosis requires abdominal ultrasound, and treatment is generally surgical.

A 7-year-old boy with a PMH of headaches presents with increased frequency and severity of headaches along with new onset vomiting. When the patient was walking into the room, he had a wide stance and nearly tripped twice. Which of the following is the most appropriate next step? A Daily headache diary B Computed tomography C Magnetic resonance imaging D Lumbar puncture E Intraventricular pressure monitoring

B. CT imaging does not visualize posterior fossa as well as MRI and would not be modality of choice if MRI is available. ***C. MRI is more expensive and less readily available than CT imaging. It also frequently requires sedation in pediatric patients. However, it provides the best detail of the posterior fossa, which is the most common location of pediatric brain tumors. D. Lumbar puncture can be very helpful in diagnosis of meningitis. Lumbar puncture is contraindicated in patients with signs of increased ICP because it may lead to brain herniation. E. Intraventricular pressure monitoring involves placement of intraventricular catheter, which measures pressure inside skull and sends measurements to a recording device. This option may reveal increased intracranial pressure, but would not be helpful in diagnosis. A brain MRI would be more appropriate.

A 9-year-old male presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. He has struggled with these complaints over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him? A Oral antibiotics B Short-acting beta agonist PRN C Short-acting beta agonist PRN with low-dose inhaled corticosteroid D Short-acting beta agonist PRN with medium-dose inhaled corticosteroid E Long-acting beta agonist

B. Cough and wheezing that occur intermittently (< 2 days/week) are consistent with intermittent asthma, which is treated with short-acting beta agonist PRN. ***C. Persistent cough and wheezing that affect the patient every other day (3-4 days with symptoms/week) are consistent with mild persistent asthma, which is appropriately treated with short-acting beta agonist PRN and low dose inhaled corticosteroid. The swelling under the eyes (allergic "shiners") and skin rash are other signs of atopy, as mentioned above. D. Short-acting beta agonist PRN with medium dose inhaled corticosteroid is the preferred treatment for moderate or severe persistent asthma, which corresponds to daily symptoms or symptoms throughout the day. E. The use of a long-acting beta agonist is reserved for severe persistent asthma, which corresponds to symptoms throughout the day.

A newborn baby boy is born at 30 5/7 weeks' gestation after induction of labor for the severe maternal preeclampsia. He is noted to have subcostal and intercostal retractions, grunting, nasal flaring, persistent cyanosis, and tachypnea 30 minutes after delivery. Apgars were 6 (-2 for color, -1 for breathing and -1 for tone) and 7 (-2 for color and -1 for breathing) at 1 and 5 minutes, respectively. Due to lack of prenatal care and the mother's presentation with severe preeclampsia, betamethasone x 1 was given during induction, but she did not receive a second dose prior to delivery. A chest x-ray is obtained, which reveals diffuse ground-glass appearance and air bronchograms bilaterally. What is the most likely diagnosis? A Meconium aspiration syndrome (MAS) B Respiratory distress syndrome (RDS) C Persistent pulmonary hypertension (PPHN) D Transient tachypnea of the newborn (TTN) E Bronchopulmonary dysplasia (BPD)

B. This choice is correct. The baby boy is preterm, and his mother received only one dose of betamethasone, which puts him at increased risk for developing infant RDS, which is caused by insufficient surfactant. His physical exam and chest x-ray findings are consistent with RDS. A. This choice is incorrect. Although the presence or absence of meconium was not noted in the case, it is known that from 20 to 34 weeks' gestation, the fetus will pass meconium infrequently. Most cases of MAS are in term or post-term infants. On chest x-ray, we might see overdistention of the lung or other sequelae, such as pneumothorax. C. This choice is incorrect. PPHN generally occurs in babies born after 34 weeks. There are several causes for PPHN: underdevelopment, maldevelopment, and maladaptation. Underdevelopment of the lungs can be secondary to congenital diaphragmatic hernia, oligohydramnios in utero, IUGR, or renal agenesis. The underdevelopment causes increased pulmonary vascular resistance and has a poor prognosis. Maldevelopment involves remodeling of pulmonary vasculature and is associated with post-term delivery and meconium aspiration syndrome. Maladaptation can be caused by infection with GBS. Vasoactive mediators are activated by bacterial phospholipids, causing an increase in pulmonary vascular resistance. D. This choice is incorrect. TTN is a disorder of delayed reabsorption of fluid in the newborn's lungs. Prematurity, delivery by C-section, being large or small for gestational age, or having a diabetic mother are all risks. In order to be diagnosed with TTN, the baby would need to show improvement within several hours. Although this is on the differential for the newborn baby's condition based on clinical presentation, a chest x-ray should have shown perihilar streaking and other evidence of interstitial fluid. E. This choice is incorrect, because BPD is the result of prolonged mechanical ventilation. Our patient is at risk for developing this syndrome if he requires intubation. Chest x-ray may show atelectasis, inflammation, or pulmonary edema. With severe disease, the chest x-ray may reveal fibrosis and hyperinflation.

What should be drawn before starting abx in suspected sepsis?

Blood and urine

Stages of puberty in the male

Boys start puberty between 10 and 15 years of age 1) Growth of testicles ( age 12 years) then, 2) Pubic hair appears (age 12 years) then, 3) Growth of penis, scrotum (age 13-14 years) 4) First ejaculations (age 13-14 years) then, 5) Growth spurt (age 14 years) then, 6) Attainment of adult height (age 17 years)

CRAFT questions

C Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs? R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A Do you ever use alcohol/drugs while you are by yourself, ALONE? F Do you ever FORGET things you did while using alcohol or drugs? F Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? T Have you gotten into TROUBLE while you were using alcohol or drugs?

You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient? A Perform a brain-stem auditory evoked potential hearing screen B Perform a screening exam for autism C Reassure parents that boy's development appears normal D Refer the child to a developmental specialist for comprehensive evaluation E Refer the child to a specialist for evaluation of his delayed motor development

C has been selected by the expert. A. A brain-stem auditory evoked potential hearing test (BAER) may be indicated in infants who fail to meet language milestones if they cannot cooperate with other more comprehensive testing. A 36-month-old should be able to cooperate with behavioral audiometry, so a BAER is not indicated. In addition, this child has no evidence of language delay and does not require referral at this point. B. Autism is an increasingly diagnosed cause of developmental delay, but this child is not delayed and no mention is given of any autistic features, such as a lack of symbolic play, repetitive movements, or poor sociability. C. The developmental milestones mentioned in the vignette are within the range of normal for a 36-month-old child. In the absence of any other evidence of significant impairment, there is no indication for referral at this point. D. If there are reasons for concern on developmental screening tests, a referral may be indicated. However, the developmental milestones mentioned in the vignette are within the range of normal for a 36-month-old child. E. This child's motor milestones are not delayed, and no referral is indicated.

A 5-year-old boy is noted to have a grade II systolic murmur and a widely split S2 murmur on cardiac exam. His vital signs are stable and he has been asymptomatic. Which of the following statement is accurate regarding this patient's presentation and likely condition? A No further work-up for a presumed venous hum B Chest x-ray, ECG, and echocardiogram would be indicated as next steps to work up a presumed ventricular septal defect C This patient's murmur is caused by flow through the pulmonary outflow tract and should be evaluated D The patient should be scheduled now for cardiac catheterization

C has been selected by the expert. A. Incorrect. A benign venous hum would not be expected to present with a widely split second heart sound. B. Incorrect. The first steps in the evaluation of presumed structural heart disease would include a chest x-ray, ECG, and echocardiogram. However, the clinical presentation is not consistent with a ventricular septal defect, which usually presents with a holosystolic murmur and a second heart sound that splits variably with respiration. C. Correct. This patient's murmur is likely caused by an atrial septal defect, which causes flow of additional blood through the pulmonary outflow tract and should be evaluated. D. Cardiac catheterization might be indicated to better define this patient's anatomy, and the pressures within each cardiac chamber. However, it would not be indicated to schedule this before a preliminary work-up, including a chest x-ray, ECG, and echocardiogram.

A 45-day-old infant is brought in by his mother due to lethargy, constipation, and yellow skin color noted since birth. The mother and the baby moved to the U.S. from a foreign country that does not screen its newborns. The baby has been fed only formula since birth. Physical exam of the neonate reveals additional findings of large fontanelles, umbilical hernia, a large tongue, and abdominal distension. What is the next best step in diagnosis? A Phototherapy B Exchange transfusion C TSH D Head ultrasound E Obtain a family history of jaundice to rule in or out a defect in bilirubin metabolism

C has been selected by the expert. A. Phototherapy is the treatment for physiologic jaundice, which peaks at three to four days and resolves by the fourth or fifth day of life. Lethargy, macroglossia, and umbilical hernia are not known to be caused by or associated with physiologic jaundice. This constellation of physical exam findings is more consistent with untreated congenital hypothyroidism. B. This choice is incorrect because this is the management of infants with hyperbilirubinemia approaching levels of concern for kernicterus. C. This choice is correct because the constellation of baby's problems is best accounted for by untreated congenital hypothyroidism. Unfortunately, severe mental retardation is unavoidable at this point because this condition should have been treated since birth. In the U.S., it would have been detected on the newborn screen. D. This choice is incorrect as there is no indication of hydrocephalus or concern for bleeding. E. This choice is incorrect because—although defects in biliary metabolism such as Gilbert's syndrome, seen in 5% of the population, can cause harmless jaundice—this patient has many other findings in addition to jaundice. Of the answer choices given, only congenital hypothyroidism fully accounts for the entire constellation of findings.

A 3-year-old boy presents for a follow-up visit after being diagnosed with iron deficiency anemia. He is currently receiving oral iron supplements, 2 mg/kg of elemental iron daily. He has a dietary history of eating mostly sweet, bland, low-texture foods. What strategies may be used to improve his diet? A Continue bottle-feeding B Encourage eating small amounts of food throughout the day (grazing) C Gradually introduce new foods and slowly decrease his old favorites D Bargain and cajole with the child E No change is needed; bland, low-texture foods are optimal for a child this age

C has been selected by the expert. A. This choice is incorrect because the child should stop bottle-feeding now to improve his diet. Children usually stop requesting the bottle a few days after it has been discarded. B. This choice is incorrect because the child should be encouraged to restrict eating to 3 meals and 2 snacks per day, instead of "grazing" throughout the day. C. This choice is correct, because gradually introducing new foods and slowly decreasing his old foods will likely ease the transition to healthier diet choices and encourage long-term adjustment. D. This choice is incorrect because bargaining and cajoling is unlikely to be effective. He should be presented with healthy options only, and dessert should not be used as an incentive for healthy eating. E. This choice is incorrect because the child's current diet is not optimal. He should be eating a varied diet with the recommended servings of fruits and vegetables per day.

John is a 17-year-old presenting today for a pre-participation physical exam. During the interview, he reports a low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a temperature of 101.3° F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His participation would be most likely affected by which of the following tests? A Chest x-ray B CT head/neck C EBV serologies D Throat culture E No further workup

C has been selected by the expert. A. This choice is incorrect because there is no evidence of lower respiratory tract signs or symptoms. B. This choice is incorrect because the additional exposure to radiation is not warranted given the availability of other higher priority tests. C. This choice is correct because the patient's symptoms are suggestive of infectious mononucleosis. These include complaints of low-grade fever and malaise and findings of cervical lymphadenopathy and pharyngeal exudate. If testing is positive, the patient should be restricted from strenuous activity or contact sports during his illness due to the risk of splenic rupture. D. An antigen test (and culture, if negative) should be performed for streptococcal pharyngitis, but this clinical picture is more consistent with EBV, and mononucleosis is more likely to preclude participation in sports. After 24 hours of antimicrobials, the patient with streptococcal pharyngitis is no longer contagious. E. This choice is incorrect because the patient's symptoms and findings warrant further evaluation.

A 12-day-old baby girl is brought to the ED by her foster mother due to fussiness and tactile fevers. The baby's teenage biological mother did not receive prenatal care and delivered her baby at home. On further questioning, you find out that the patient has had only two wet diapers per day and two loose green stools per day. On exam, the patient is irritable and her anterior fontanelle is tense. Which of the following diagnoses are of emergent concern at this time? A Down syndrome B Fetal alcohol syndrome C Group B strep sepsis/meningitis D Meconium ileus E Poor weight gain

C has been selected by the expert. A. This choice is incorrect, because although the patient is likely to have missed newborn screening for Down syndrome, her most emergent concern is her fever and possible sepsis. B. This choice is incorrect. Although the patient is at risk for fetal alcohol syndrome (since her mother did not have prenatal care and may not have had counseling regarding abstinence from alcohol), her most urgent concern is her fever in a less than 1-month-old infant. C. This choice is correct. The patient's mother did not have prenatal care and likely did not have screening for group B strep during pregnancy. She also delivered at home and would not have had access to antibiotics during delivery. Group B strep is a common and serious cause of sepsis and meningitis in newborns. D. This choice is incorrect because the patient reportedly has passed stool since delivery. E. This choice is incorrect. Infants may lose weight during the first few days of life, but are expected to regain their birth weight by 2 weeks of age.

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? Please select one answer. A 12 months B 15 months C 18 months D 30 months E 36 months

C has been selected by the expert. At 18 months, a child should be able to walk backward, and 50-90% of children can run at this stage. An 18-month-old should be able to scribble, build a tower of 2 cubes, have 3-6 words in her or his vocabulary, and be able to help in the house and remove garments. A. At age one year, gross motor skills include pulling to stand, standing alone, and perhaps first steps. Fine motor skills including putting a block in a cup and banging 2 cubes held in hands. At this age a child should be able to imitate vocalizations/sounds and babble. The majority of children this age will know 1 or 2 words in addition to "mama" and "dada." Social-emotional milestones at age one year are waving bye-bye and playing pat-a-cake. Running, building towers of blocks, removing clothing, and a 6-word vocabulary are more advanced skills than a 12-month-old would be expected to have. B. At 15 months of age, a child should be able to stoop and recover and walk well, put a block in a cup, have a vocabulary of a few words, wave bye-bye, and drink from a cup. Running, building towers of blocks, removing clothing, and a 6-word vocabulary are more advanced skills than a 15-month-old would be expected to have. D. At 2 ½ years of age, kids can jump up and throw a ball overhand. They can build a tower of 6-8 cubes, point to 6 body parts, name 1 picture, put on clothing, and wash and dry their hands. Sammy is only able to build a tower of 2 cubes, can remove his clothing but does not yet put clothing on, and his vocabulary is limited to 6 words—leading us to believe he is not 2 ½ years old. E. At age 3, children can balance on each foot for 1 second, wiggle their thumbs, name 4 pictures, name 1 color, name a friend, and brush their teeth with help. Sammy's vocabulary is only 6 words, he is not able to name a friend, he is only able to stack 2 cubes, and he has just starting running, but is unable to balance on each foot for 1 second.

A two-month-old female presents to clinic for a well-baby checkup. Mom has been happy because the "baby rarely cries and sleeps all the time." On exam, the baby has yellowing of the skin, decreased activity, appears to have decreased tone, and a large anterior fontanel. What is the most likely diagnosis? A Sepsis B Congenital adrenal hyperplasia C Congenital hypothyroidism D Shaken baby syndrome E Neonatal lupus

C has been selected by the expert. Congenital hypothyroidism may not be clinically evident until 6 weeks of age due to circulating maternal thyroid hormone transmitted from placenta. Signs and symptoms of congenital hypothyroidism include feeding problems, large fontanels, hypotonia, large tongue, coarse cry, and frequently an umbilical hernia. Congenital hypothyroidism should be picked up on routine neonatal screening. A. Sepsis is a blood infection of the infant. Signs and symptoms may include body temperature change, changes in respiration, increased or decreased heart rate, reduced movement, reduced feeding, low blood sugar, seizures, and jaundice. B. Infants with congenital adrenal hyperplasia often have abnormal genitalia (females), poor feeding, vomiting, dehydration, and electrolyte changes. D. Shaken baby syndrome may result in significant head trauma, including subdural hemorrhage, hypoxic/ischemic brain injury, and retinal hemorrhage. E. Neonatal lupus should be considered when infant's mother has lupus. Cutaneous findings may be present at birth or may develop within the first 2 to 5 months of life. These findings include erythematous plaques, telangiectasias, or atrophic lesions. Affected infants may have cardiac abnormalities or conduction deficits. Hematologic disturbances may occur within the first 2 weeks of life.

A 5-year-old female, previously healthy, presents with an erythematous, vesicular rash on the palms and soles and a high fever for several days. Upon examination, she is also found to have ulcers in her mouth. A few days later, the fever and rash resolve. What is the most likely pathogen? A Herpes simplex virus 1 (HSV-1) B HIV C Enterovirus D Human herpesvirus 6 (HHV-6) E Group A strep

C has been selected by the expert. Consistent with infection by cocksackie A, an enterovirus. Following an incubation period of 3-5 to five days, patients have fever, tender vesicles on their hands and feet, and oral ulcers. Sometimes the rash also occurs on the buttocks and the genitals. The infection resolves spontaneously within three days, and is spread from person to person via saliva, fluid from the vesicles, stool, or nasal discharge. A. HSV-1 causes gingivostomatitis and can sometimes be accompanied by fever and malaise, but lesions on the hands and feet would be uncommon. B. HIV infection can increase risk of oral lesions secondary to infections by HSV-1 or Candida albicans, but again would be unlikely to cause lesions on hands and feet. Furthermore, at this patient's age (5 years), she is unlikely to be HIV-positive unless it was vertically transmitted from her mother. D. HHV-6 is the virus that causes roseola, which manifests as fever followed by a macular or maculopapular rash, but this rash begins on the trunk, eventually spreading to the extremities, and does not cause oral lesions. E. Group A strep infection could cause fever and a rash with scarlet fever, but this rash is described as "sandpaperlike" with small papules, not vesicular, and is also not confined to the hands and feet.

A 9-month old baby boy comes to the clinic for a well child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit? Please select one answer. A Influenza, Hep B, IPV, DTaP B Influenza, IPV C Influenza, Hep B, IPV D Hep B, DTaP, IPV E Hep B, IPV, and MMR

C has been selected by the expert. Influenza, Hep B, IPV is correct. The patient needs a third Hep B, a third IPV, and a yearly flu shot starting at 6 months of age. A. Influenza, Hep B, IPV, DTaP is incorrect. All three doses of DTaP have been given. B. Influenza, IPV is incorrect. The patient needs the third Hep B shot. D. Hep B, DTaP, IPV is incorrect. All three doses of DTaP have been given and the patient now needs a yearly flu shot starting at 6 months of age. E. Hep B, IPV, and MMR is incorrect. The patient also needs a yearly flu shot starting at 6 months of age and MMR is not given before 12 months of age.

A 2-year-old girl presents to the urgent care clinic with a 7-day history of high fever to 38.5 C, a maculopapular rash that began on the palms and soles of her feet, red eyes without discharge, and unilateral cervical adenopathy. What other symptom/sign might you discover on further history and exam? A Tonsillar exudates B Headache C Erythematous and edematous feet D White spots on buccal mucosa E Dysuria

C has been selected by the expert. The constellation of symptoms described suggests Kawasaki disease. The other two classic signs not mentioned are erythematous tongue ("strawberry tongue"), and erythema/edema of the extremities, which is the best answer here. A. Tonsillar exudates would be present in strep pharyngitis or tonsillitis. Given the prolonged fever, rash, lymph node involvement, and conjunctivitis, the disease process is more widespread than a simple tonsillitis. You should recognize this constellation of symptoms as Kawasaki disease. B. Headache would be present in Rocky Mountain Spotted Fever. This seems reasonable, given the fever and rash that began on the palms and soles. However, the other findings suggest Kawasaki disease, so this is not the best answer. D. White spots on the buccal mucosa are also known as Koplik spots, which are pathognomonic for measles. The fever and conjunctivitis could be measles, but there is no cough or coryza. In addition, the rash typically starts at the head and moves downward, rather than starting on the hands and feet. E. Although children with Kawasaki disease can have pyuria, it is not associated with dysuria, a symptom of a UTI, which would be highly unlikely given the other signs.

Jane is an 8-year-old girl who presents to your clinic for follow-up after being hospitalized for status asthmaticus. She has just completed a 10-day course of systemic steroids. Given her history of moderate persistent asthma, her outpatient regimen includes Advair, a combined steroid and bronchodilator. She was also diagnosed with ADHD one year ago and was started on Concerta, 18 gm PO once a day. Her BMI today is at the 83rd percentile for her age, and her blood pressure is at the 98th percentile for her age. What is the most likely cause of her stage I hypertension? A Obesity B The blood pressure cuff is too big C Medications D Renal insufficiency E Neurofibromatosis 1

C is correct. Both steroids and amphetamines can cause increases in blood pressure, especially when used in combination. Steroids increase blood pressure by mimicking endogenous cortisol and the sympathetic fight or flight response. Amphetamines mimic norepinephrine, stimulating alpha and beta adrenergic receptors, causing an overall increase in blood pressure. A. While obesity is a risk factor for hypertension, Jane is not overweight. A child is considered overweight when his or her BMI is between the 85th and 95th percentile for age. Obesity is considered > 95th percentile. B. Blood pressure would be falsely decreased if the cuff was too big, and, inversely, falsely elevated if the BP cuff was too small. D. Renal insufficiency can be a cause of secondary HTN, unlikely in this patient. Risk factors that warrant investigation of renal causes for hypertension include recurrent UTIs, umbilical arterial/venous lines placed while a child was in the ICU, and a family history of renal disease. E. NF-1 can be associated with HTN as a result of vascular malformations that affect blood supply to the kidneys; however, this child does not present with any signs of NF-1.

A 3-hour-old infant boy, born by C-section at 36 weeks to a 30-year-old G1P1 with Apgars of 8 and 9 at 1 and 5 minutes, respectively, is found to be tachypneic in the newborn nursery. His mother has a history of Type II diabetes that was poorly controlled during her pregnancy. She was compliant with prenatal vitamins and took no other drugs during her pregnancy. Prenatal labs, including GBS, were negative. The mother's membranes ruptured 9 hours prior to delivery, she was afebrile, and the amniotic fluid had no meconium. On physical exam, the infant is large for gestational age. He has good air movement through the lungs bilaterally, without retractions or nasal flaring. He appears well perfused with normal cardiac exam. He is not in a flexed posture and has a weak suck reflex. A screening test at 3 hours of life reveals blood glucose of 39 mg/dL. What is the most likely diagnosis? Please select one answer. A Hypoglycemia B Transposition of the great arteries C Transient tachypnea of the newborn D Neonatal sepsis E Pneumothorax

CORRECT A. Hypoglycemia is a common presentation in an infant born to a diabetic mother with poor glucose control during her pregnancy. The increase in maternal serum glucose stimulates fetal pancreatic beta cells to increase insulin production, and this hyperinsulinemic state leads to hypoglycemia when the placental glucose supply is discontinued after delivery. At < 4 hours of life, a glucometer reading of < 25 mg/dL without symptoms or < 40 mg/dL with symptoms would require intervention to correct the hypoglycemic state. This infant has signs of hypotonia, with absence of flexed posture and weak suck, and a blood glucose reading of 39 mg/dL, making hypoglycemia the most likely diagnosis. B. Transposition of the great arteries is a congenital heart defect in which the aorta and pulmonary artery are switched, resulting in poorly oxygenated blood pumped into the systemic circulation. The infant with transposition is generally cyanotic and will be in respiratory distress. This congenital defect is usual accompanied by a VSD, and maternal diabetes is a risk factor. This infant appears well perfused on exam, and has no murmurs on cardiac exam, making transposition a less likely diagnosis. C. Transient tachypnea of the newborn (TTN) is a condition characterized by delayed clearance of amniotic fluid from the infant's lung following birth (persistent postnatal pulmonary edema) resulting in respiratory distress. Infants born by C-section and to diabetic mothers are at an increased risk of TTN. X-ray findings include "wet" appearing lungs with significant perihilar streaking, interstitial and alveolar fluid, and fluid in the pleural space and along the fissures. TTN generally resolves within 24 to 48 hours and is treated symptomatically. D. Neonatal sepsis is most commonly caused by GBS, Listeria and E. coli, transmitted from mother to baby. Additional risk factors include premature rupture of membranes (> 18 hours prior to delivery), preterm delivery, and chorioamnionitis. Infants may present with fever, trouble breathing, jaundice, and lethargy. Our infant is premature and tachypneic, but he is afebrile with normal Apgars and no evidence of altered level of alertness. Furthermore, mother was GBS negative, afebrile (no chorioamnionitis), with no premature rupture of membranes, making this diagnosis less likely. E. Pneumothorax is collapse of lung tissue secondary to air accumulation in the pleural space. Risk factors for pneumothorax in an infant include previous intubation or underlying lung disease (such as severe respiratory distress syndrome). Characteristic physical exam findings include asymmetric breath sounds or decrease in breath sounds on one side. This infant has good air movement in bilateral lung fields, making this diagnosis less likely.

A male infant weighing 3200 grams is born to a G1P1 female at 39 weeks' gestational age via planned C-section. Maternal PMH is unremarkable, and GBS status is unknown. Apgars are 7 and 8 at 1 and 5 minutes of life, respectively. The delivery is uncomplicated, and the infant initially appeared in good condition. However, one hour following delivery the infant develops increasing respiratory distress. RR is assessed as 90 breaths/min. All other vital signs are within normal limits. On exam, the infant is acyanotic with rapid respirations and robust capillary refill. Chest x-ray shows bilateral lung fields with the appearance of "a radio-opaque line of fluid in the horizontal fissure of the right lung." No air bronchograms are noted. What is the most likely etiology of the infant's respiratory distress? A Transient tachypnea of the newborn (TTN) B Respiratory distress syndrome (RDS) C Neonatal sepsis D Meconium aspiration

CORRECT A. Transient tachypnea of the newborn (TTN) is the most likely underlying etiology. This condition is caused by residual fluid in the infant's lungs following delivery, and usually resolves within several days. It is more common in babies delivered via C-section, as the normal mechanical force of labor that helps expel fluid from the lungs is lacking. Babies with TTN and other forms of respiratory distress are often unable to nurse and require feeding via NG tube until respiratory status stabilizes. B. Respiratory distress syndrome (RDS) is less likely than TTN in this case. RDS is more common in premature infants and infants born to diabetic mothers. On chest x-ray, RDS is characterized by a ground-glass appearance and air bronchograms. C. Neonatal sepsis is possible, especially given the mother's unknown GBS status, but relatively unlikely compared to the other options, especially given the mode of delivery. Sepsis can certainly cause respiratory distress and, if suspected, should be promptly evaluated with screening labs and blood cultures. Neonatal sepsis is also more common with prolonged rupture of membranes (PROM) > 18 hours prior to delivery. D. Meconium aspiration can lead to respiratory distress, but seems less likely in this case given the infant's delivery via C-section. Additionally, meconium aspiration is more common when meconium is found in the amniotic fluid and/or products of conception. No mention of this was made in the above case description.

An 8-year-old boy is brought to clinic by his parents because they are concerned that he has not been doing his homework. His teacher recently called the parents to say that their son seems distracted in class, constantly interrupts other children when they are speaking, and is very fidgety. When you speak with the boy, he tells you that he did not know about the homework assignments and that he tries hard to pay attention in class. What is the next best step in management? A Prescribe a stimulant medication for ADHD B Suggest behavior modification for the child and parenting classes C Group therapy for the child D Do nothing, as this child's behavior is normal E Contact the teacher to find out more about his behavior. Find out more about the child's behavior at home

CORRECT E A. Pharmacotherapy is often used in combination with behavioral modification/group therapy for children diagnosed with ADHD. However, to be diagnosed with ADHD, one must have 6 or more symptoms in 2 or more settings for at least 6 months, and several of these symptoms must be present before the age of 12. The symptoms fall within the three categories of inattention, hyperactivity, and impulsivity. B. Behavior modification for the child and parenting classes for the parents are both used as treatment modalities in ADHD. Parents should be counseled on positive reinforcement, firm non-punitive limit setting, and how to reduce external stimuli. However, this child first requires further evaluation. C. Children with ADHD often learn best in group therapy, particularly social skills and self-esteem. Again, this child first requires further evaluation. D. Many school-aged children are easily distractible, impatient, and hyperactive. It is important to distinguish those who truly have ADHD from those who do not. Again, to have a diagnosis of ADHD, symptoms must be present in two or more settings. E. Contacting the teacher to find out more about the child's behavior at school and learning more about his behavior at home are the best ways to determine if 6 of the symptoms are present in 2 or more settings, which is required to make the diagnosis of ADHD. It also will be important to learn more about other aspects of this child's life, as there are several factors that can lead to acting out (including learning disability, hearing disability, family stress, and abuse).

What is rapid correction of hyponatremia associated with?

Central pontine myelinolysis - Neurologic disease caused by damage of myelin sheath of nerve cells in brainstem, more precisely in pons.

Best oral Antibiotic Selection for Pyelonephritis

Cephalexin (Keflex): Best choice: inexpensive and well tolerated, 10 days

What is cystic PVL associated with?

Cerebral palsy

2-year-old male presents to the ED with a 5-hour history of hyperactivity, fever, and sweating. His BP is 160/90 mmHg, HR 130 bpm, RR 30 bpm. On exam, he has dilated pupils, cool skin, and hyperreflexia. What is his most likely accidental medication ingestion? A Pseudoephedrine B Codeine C Iron pill D Acetaminophen E Propranolol

Choice A is correct. Ingestion of a sympathomimetic like pseudoephedrine stimulates beta and alpha adrenergic receptors, causing elevated HR, RR, BP and hypothermia along with diaphoresis, dilated pupils, hyperreflexia, and hyperactivity. B. Choice B is incorrect because constricted pupils are seen in ingestions of opioids. Slowed breathing, rather than tachypnea, may also be seen. C. Choice C is incorrect. Iron toxicity would present with severe abdominal symptoms followed by signs of shock. D. Choice D is incorrect. Acetaminophen toxicity initially presents with minimal symptoms, followed by symptoms of liver toxicity such as jaundice and RUQ pain. E. Choice E is incorrect. Beta-blocker toxicity would cause bradycardia, not tachycardia and hypertension.

A 3-year old girl comes to the clinic with a chief complaint of fever (104F) for over a week. Her mom reports that she has been fussy and inconsolable since she became febrile. She has a red tongue, with large papillae, conjunctivitis, a palmar rash, unilateral cervical adenopathy, as well as swollen feet. Given the most likely diagnosis, what is the most important follow-up for this patient over the next few weeks? A Ophthalmology follow-up to determine extent of eye damage and determine need for corticosteroids B Physical therapy follow-up to help prevent long-term joint deformities and ensure long-term functionality C Cardiology follow-up to rule out presence of rheumatic fever D Echocardiogram to look for coronary artery aneurysm E Neurology follow-up to evaluate partial paralysis of lower extremities

Choice D is correct because children with Kawasaki disease are at high risk for coronary artery aneurysm formation and should receive an echocardiogram within four weeks of the onset of their illness. Use of IVIG for the treatment of Kawasaki disease has decreased the risk of coronary artery aneurysms significantly. Kawasaki disease is diagnosed when there is a fever plus four of the following: changes in oral mucosa (e.g., strawberry tongue), extremity swelling or redness, unilateral cervical adenopathy, conjunctivitis, and rash. Infectious and rheumatologic causes must be excluded in order to make the diagnosis of Kawasaki disease.

IO complications

Complications of IO cannulation are rare (less than 1%) but include: - Fractures - Compartment syndrome. - Osteomyelitis - Microscopic fat and bone marrow emboli. - Only reported deaths resulting from IO infusions were associated with using the sternal approach.

Adam is a 2-hour-old infant born at 32 weeks' gestational age via spontaneous vaginal delivery to a healthy mother with negative group B streptococcus status. There was no premature rupture of membranes and no meconium in the amniotic fluid. His Apgars were 8 at one minute and 9 at five minutes. Over the last two hours he has become progressively tachypneic. On physical examination he is large for gestational age. His vital signs are respiratory rate 75, temperature 36.5 C and heart rate is 130 beats per minute. His lung exam is remarkable for intercostal and subcostal retractions, grunting, and equal breath sounds. His heart exam reveals normal rhythm, normal S1 and S2, no murmurs, and normal peripheral pulses and capillary refill. Which of the following is the most likely cause of the patient's condition? A Transient tachypnea of the newborn (TTN) B Pneumothorax C Congestive heart failure D Respiratory distress syndrome E Sepsis

Correct answer D. RDS causes tachypnea and is therefore an important consideration in this case. RDS is more common in premature infants. Given lack of history of maternal diabetes, NSVD birth, and few risk factors for sepsis other than prematurity, Adam is likely to have RDS. A. Transient tachypnea of the newborn (TTN) is much more common in infants born to diabetic mothers. TTN is unlikely because he is 32 weeks, very premature, and was born via NSVD. RDS is much more likely, although TTN is still a possibility and would need to evaluated with a CXR. B. Pneumothoraces are uncommon, but should always be considered in an infant with respiratory distress. Good bilateral air entry argues against this diagnosis. C. Congestive heart failure is an important cause of tachypnea. Adam has a normal cardiovascular exam, with no murmur, normal pulses, and good capillary refill. Infants with congestive heart failure usually present with the triad of tachypnea, tachycardia, and hepatomengaly. E. Infants may present with respiratory distress from sepsis or from pneumonia. In this case, Baby Adam has a normal temperature, good blood pressure, and normal perfusion. While less likely, this diagnosis should always be considered in infants with respiratory distress.

A 14-year-old girl presents to your office wondering why she has not had her period yet. Her mother states that she and the patient's grandmother reached menarche at 13 years of age. The patient is concerned she is behind her friends in terms of development. She is doing well in school and has not had developmental problems in the past. On physical examination, her breasts are elevated without a secondary mound, and curly, coarse pubic hair is present on the labia majora in a triangular shape but does not reach the mons pubis. What Tanner stage would you assign this patient? A Tanner Stage I B Tanner Stage II C Tanner Stage III D Tanner Stage IV E Tanner Stage V

Correct is C A. Tanner Stage I breast development consists of no glandular tissue and is prepubertal. Tanner Stage I consists of no pubic hair at all. This is usually around age 10 or younger. B. Tanner Stage II breast development occurs when breast buds form and the areola begins to widen. A small amount of long, downy hair with slight pigmentation appears on the labia majora. This patient's elevated breast buds and pubic hair distribution puts her beyond Tanner Stage II. C. The patient in the vignette is at Tanner Stage III of development. Her breast buds are elevated but do not have the secondary mound characteristic of Tanner Stage IV. Her pubic hair distribution extends more laterally than Stage II but is not adult-like in hair quality and does not extend onto the mons pubis. D. In Tanner Stage IV, breasts are increased in size and elevation and the areola and papilla form a secondary mound that projects from the contour of the rest of the breast, and the pubic hair extends across the mons pubis and spares the medial thighs. E. In Tanner Stage V, breasts reach their adult size and the areola returns to the contour of the surrounding breast while the central papilla remains projecting and the pubic hair extends to the medial surface of the thighs.

A 17-year-old boy presents for a sports pre-participation physical. He reports that he occasionally gets short of breath and feels light-headed with exercise, and sometimes he experiences chest pain as well. He lost consciousness once last season during a playoff basketball game, but attributed it to feeling sick at the time. His grandfather died suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis? A Hypoglycemia B Congenital heart block C Postural hypotension D Prolonged QT syndrome E Ventricular septal defect

D has been selected by the expert. A. Hypoglycemia is very uncommon in healthy children. It is usually associated with diaphoresis, anxiety, tremulousness, and a feeling of hunger. Chest pain and shortness of breath are less likely. B. Congenital heart block can be caused by congenital heart defects and autoimmune disease in pregnant women (lupus). This condition is a rare cause of arrhythmia and is often diagnosed early in life. Many patients require a pacemaker. C. Postural hypotension is a very common cause of dizziness and visual changes in the pediatric population. It is usually triggered by volume depletion and skipping meals. Hypotension is not usually associated with shortness of breath, chest pain, and prolonged (> 5 min) loss of consciousness. D. Prolonged QT syndrome can cause syncopal episodes in late childhood or adolescence. QT intervals are elongated on ECG and lead to arrhythmias, like ventricular fibrillation. This condition is often associated with other abnormalities, including severe congenital sensorineural deafness. E. Ventricular septal defects often have negligible cv sequelae, or will close up on their own after a # of years. If they are not monitored, however, shunting can cause hypertrophy of the right heart, called Eisenmeiger syndrome, which could result in pulmonary hypertension, exercise intolerance, and eventual heart failure. It would be unlikely, however, to cause chest pain or syncope. The family history of sudden cardiac death also points to prolonged QT rather than a VSD.

The parents of 5-month-old Tiffany are concerned about Tiffany's decreasing oral intake over the past 4 days. They report that she has been sleeping more but seems to tire out when feeding; in fact, mom's breasts have become quite engorged and she needs to pump to relieve the pressure. In addition to the sleepiness and poor feeding they report that she has not had a bowel movement in 3 days. She has no fever or respiratory symptoms. You note a weak cry on your exam, and a floppy baby when you try to sit her up. What additional finding are you likely to find on your exam? A Vesicular rash on her scalp B Large tongue and umbilical hernia C III/VI systolic murmur D Absent deep tendon reflexes E Cataracts and hepatosplenomegaly

D has been selected by the expert. A. A vesicular rash may be seen in neonatal HSV infection, which can be a cause of encephalitis. It is less likely in this older age group and would most likely present with fever and possibly seizure. B. Although congenital hypothyroidism can present with lethargy, constipation, and poor feeding, the infant would be less likely to present with these symptoms as late as 5 months of age. C. Congenital heart disease may present with poor feeding, but a large VSD would likely present earlier and would not be associated with constipation and hypotonia. D. This infant likely has infant botulism which usually presents in the first year of life with hypotonia, lethargy, constipation, weak cry and can eventually lead to respiratory failure. These infants will have absent DTRs. E. An inborn error of metabolism can present with lethargy and poor feeding—and hepatosplenomegaly and eye findings may also be present—but this infant presented more acutely and at an older age than would be expected for a metabolic disorder.

A 10-day-old boy is brought to the ED by his mother because of "fever." Mom describes that the baby has been "sleepy" and feeding less vigorously than in the previous two days. She believes his urine output has also decreased. His birth history is notable for prolonged membrane rupture (about 32 hours), and maternal fever at the time of delivery. Prenatal and neonatal ultrasound revealed bilateral hydronephrosis. On exam, the infant is sleepy with a temperature of 38.5 C. A blood sample is sent for CBC, BMP, and culture. Attempts are made to obtain CSF and urine for analysis and culture, but only very small volumes of these fluids are obtained. Volume resuscitation is begun. Chest x-ray is performed with indeterminate results. What is the most appropriate next step? A Send samples for gram stains and begin parenteral empiric antibiotic treatment B Send the urine for urinalysis and the CSF for cell count, glucose and protein and begin parenteral antibiotic therapy C Admit for observation and continue supportive care D Send samples for culture and begin parenteral antiobiotic treatment E Attempt to obtain larger samples. Antibiotics should not be started until all needed results are pending.

D has been selected by the expert. A. Although sending samples for gram stain may give an indication of whether an infection is present, it will not give the same degree of information as would a culture with sensitivities. B. Urinalysis and CSF profiles may help us make the diagnosis, but if positive in the absence of cultures, will commit us to a prolonged course of broad-spectrum and non-specific therapy. C. Delay of therapy would not be indicated. In an infant younger than one month, fever with any suspicion of sepsis, whatever the source, requires immediate evaluation and initiation of antibiotic treatment. D. Given the presentation of fever in a neonate who presents with sleepiness and poor feeding, samples should be sent for culture and the baby started on empiric antimicrobial therapy. This infant is likely to have a urinary tract infection, and urosepsis is certainly a possibility, especially given his known urinary tract anoamlies. We have no way of ruling out meningitis from this presentation, so antibiotics should be initiated at meningitic dosing. In an infant younger than one month, fever with any suspicion of sepsis, whatever the source, requires immediate evaluation and initiation of antibiotic treatment. Because infants at this age have immature immune systems, they do not localize infections as well as older children. An infection of the urinary tract may lead to bacteremia, which in turn may lead to CNS infection. Only cultures will give us the information required to determine the appropriate type length of antimicrobial therapy. E. Given the consequences of significant bacterial infection in an infant this age, delaying therapy to obtain additional laboratory specimens is not appropriate.

A concerned mother brings her 7-day-old son to your office after noticing yellowing of his skin for 2 days. She has also noticed he has not been gaining weight since she brought him home from the hospital 5 days ago. This is her first son and she has been trying to do everything perfectly, including breastfeeding him, since she was told that breast milk provides adequate nutrients and other healthy benefits, like antibodies and growth factors. However, upon further questioning, she is feeding him only 6 times a day for 10 minutes each time. She admits her breasts often feel full and are not relieved by nursing. He was born full term by spontaneous vaginal delivery but had a hard time sucking with breastfeeding. Upon exam, he looks dehydrated and appears to have jaundice of the face and chest. He has also lost > 10% of his birth weight. What could be the cause of his jaundice? Please select one answer. A Breast-milk jaundice B Physiologic jaundice C Sepsis D Breastfeeding jaundice E Crigler-Najjar syndrome

D has been selected by the expert. A. Breast-milk jaundice is incorrect, because although it is a cause of jaundice associated with breastfeeding, it is NOT a result of low milk volume. In the above vignette, the infant does not appear to be breastfeeding well, which is multifactorial—poor suck and low number of feeds for the infant. Breast-milk jaundice would appear only if the infant were feeding well, although it is not completely understood what causes this form of jaundice. B. Physiologic jaundice is incorrect because this jaundice usually peaks at 3-4 days of life to full-term, healthy infants. This type of jaundice is not associated with breastfeeding but could be from numerous factors such as increased bilirubin production from short-lived RBCs or lack of intestinal flora to metabolize bile. No treatment is required for this type and it typically resolves on its own. C. Sepsis is incorrect because the infant does not clinically appear sick or toxic, and jaundice would be just one sign of a serious infection. Other symptoms may include respiratory distress, lethargy, poor feeding, vomiting, apnea, and temperature instability. Sepsis causes an elevated total and direct bilirubin and is highly unlikely when jaundice is the only symptom. Breastfeeding can have some protection against infection. D. Breastfeeding jaundice is the correct answer because it usually appears early in the first week of life and is caused by various factors, including poor breast milk intake. A decreased milk supply leads to limited enteral intake and can lead to increased enterohepatic circulation. Increased enterohepatic circulation describes the process where unconjugated bilirubin is reabsorbed in to the bloodstream where it binds to albumin and is recirculated. E. Crigler-Najjar syndrome is an incorrect choice because it appears within the first days of life and persists thereafter and is a relatively rare disease. This type of jaundice is caused by decreased bilirubin clearance from deficient or completely absent UDPGT (the enzyme that conjugates bilirubin with glucuronide to make it water-soluble and able to undergo excretion into bile).

Billy, a 7-year-old boy, presents to the clinic with complaints of headaches and episodes of feeling sweaty and flushed. He also reports that at times he feels as if his heart is racing. Billy was full term, had an uncomplicated birth, and has been otherwise healthy until now. On exam his BP is 120/80 mmHg and is the same in his upper and lower extremities. His weight and height are in the 50th percentile for his age. What is a likely cause of Billy's hypertension? A Coarctation of the aorta B Renal vascular disease C Renal insufficiency due to renal scarring D Catecholamine excess E Primary hypertension

D has been selected by the expert. A. Coarctation of the aorta should be suspected in a child with elevated BP (usually > 99th percentile), little family history of HTN, and a discrepancy between upper and lower extremity BPs. Some children with coarctation of the aorta may go undetected until presenting with hypertension at a school-age visit. It is important to pay special attention to the femoral pulses and to document BP measurement in a lower extremity. Billy's BPs in his upper and lower extremities are the same, making this diagnosis less likely. B. Umbilical arterial or venous lines as neonate (most often in premies) can predispose a child to renal vascular disease. Billy had an uncomplicated birth and did not go the neonatal ICU, making it less likely that his hypertension is due to renal vascular disease secondary to an umbilical arterial or venous line as a neonate. C. Recurrent urinary tract infections in childhood are one of the leading causes of hypertension and renal insufficiency later in life due to renal scarring following infections. UTIs are more common in girls. Billy does not have a stated history of urinary tract infections, and his palpitations and flushing are not consistent with hypertension secondary to UTIs. D. Catecholamine excess (pheochromocytoma or neuroblastoma) should be suspected in a child who is hypertensive and has episodes of sudden sweating, flushing, or feels that his heart is racing. Billy is exhibiting these signs and a urine catecholamine testing would be appropriate in this case. E. Most hypertension in children over 6 years of age, and in adolescents, is due to primary HTN. Obesity is an important correlate. Billy's flushing and racing heart would not be fully explained by primary hypertension. Also, Billy is an appropriate weight, making this diagnosis less likely.

George is a 7-year-old boy frequently in trouble at school for being disruptive and inappropriately talkative in class, not following directions set by his teacher, and not working well with classmates during group activities. His mother relates that at home George is always on the go, sleeping only 6 to 7 hours a night. He does not follow her rules all the time either, including not doing his homework, and sometimes putting himself in danger by doing things she tells him not to do, such as running away unaccompanied. Which of the following is the most likely diagnosis? A Bipolar mood disorder B Anti-social personality disorder C Conversion disorder D ADHD E Rett syndrome

D has been selected by the expert. A. Depression may be responsible for the inattention this child exhibits in school. It is not uncommon for childhood depression to lead to bipolar disorder, in which hyperactivity and impulsivity comprise the manic phase of the disorder leading to a decreased need for sleep. However, the symptoms of depression and mania present in separate phases, not concurrently. The mnemonic commonly used for mania is DIGFAST (distractability, irresponsibility, grandiosity, flight of ideas, agitation, sleep decrease, talkativeness). The mnemonic for depression is SIGECAPS (sleep disturbance, loss of interest, guilt, energy loss, concentration impairment, appetite changes, psychomotor retardation, suicidal ideation). B. Symptoms of anti-social personality disorder include inability to conform to societal norms, disregard of the rights of others, and often criminality. These individuals often exhibit impulsiveness due to their lack of consideration of the consequences of their actions. Males are affected more than females. However, a diagnosis of anti-social personality disorder can be made only in individuals older than 15 years, earlier than which a diagnosis of conduct disorder is appropriate. C. Conversion disorder is a subtype of somatoform disorder. Somatoform disorder would be suspected if no cause could be identified for reported physical symptoms. The drive is unconscious on the part of the patient, and symptoms are not intentionally produced or faked. Conversion disorder is more common in adolescents and involves a sudden loss of sensory or motor functioning. When the patient consciously creates physical symptoms this is referred to as factitious disorder. D. ADHD is characterized by the triad of impulsivity, hyperactivity, and inattention. Other symptoms include motor impairment and emotional labiality. ADHD is typically diagnosed before the age of 7 but persists into adulthood. Intelligence is usually normal, but individuals with ADHD commonly perform more poorly academically than would be expected for their IQ. E. Rett syndrome is an X-linked pervasive developmental disorder seen only in females; affected males die in utero or at birth. The characteristic symptoms involve regression of language and development, intellectual disability, ataxia, and hand-wringing. This disorder is typically diagnosed earlier, at about age 1-4.

A 5-day-old infant presents with a chief complaint of jaundice. As you obtain a careful history and physical examination, which of the following would NOT be a risk factor for jaundice in this infant? A Mediterranean origin B Prolonged labor with use of forceps during the delivery C Mother is type O+ and baby is type B D Phenylketonuria E Poor breastfeeding during first few days of life

D has been selected by the expert. A. Families of Mediterranean origin have higher risks of hereditary diseases that can cause jaundice. G6PD deficiency and the thalassemias are more common in Mediterranean families. Both cause hemolysis of RBCs, which results in an increased of jaundice. B. Difficult deliveries and birth trauma may result cephalohematomas, or hemorrhage of blood between the skull and the periosteum. These result from the rupture of blood vessels crossing the periosteum, usually caused by a prolonged second stage of labor or the use of forceps or other instrumentation during delivery. As the cephalohematoma resolves over weeks and the blood is reabsorbed, the breakdown of RBCs from the hematoma can result in increased bilirubin levels. C. ABO compatibility is a common cause of hemolysis in newborns. Since the mother has blood type O, she makes IgG antibodies to A-antigens and to B-antigens, leading to hemolysis of the fetal red blood cells. This can be detected by a positive direct Coombs test. D. Phenylketonuria (PKU) is an autosomal recessive metabolic disorder due to a mutation in phenylalanine hydroxylase, which is required to convert phenylalanine to tyrosine. PKU leads to buildup of phenylalanine in the brain, leading to mental retardation, seizures, and death if not detected and treated early. It is not associated with jaundice. E. Poor breastfeeding during the first few days of life and decreased enteral intake may result in breastfeeding jaundice. This may be caused by the mother who does not make enough milk, or by the infant with inadequate feeding or intake. Decreased intake leads to decreased motility of the GI tract and retention of meconium. The meconium contains β-glucuronidase, which hydrolyzes the conjugated bilirubin to an unconjugated form, which is reabsorbed and re-circulated into the blood through the enterohepatic circulation, increasing bilirubin levels in the blood.

A 3-week-old infant is brought to the pediatrician for failure to thrive (despite adequate, even prolonged, feedings) and respiratory distress (particularly tachypnea). EKG shows high voltage QRS complexes in leads V1 and V2. What other features does this infant most likely have? A Cyanosis from a right-to-left shunt B Systolic murmur with a widely split second heart sound C Continuous murmur that is louder during systole D Left-to-right shunt

D has been selected by the expert. A. Incorrect. After the pulmonary resistance of the newborn period diminishes, ventricular septal defects (VSD) present with a left-to-right shunt. If unrepaired spontaneously or surgically, this ultimately leads to increased pulmonary vascular resistance, termed Eisenmenger's syndrome. When this occurs, the pulmonary vascular resistance equals and then exceeds that of the systemic vascular resistance, leading to reversal of the direction of blood flow through the VSD to become a right-to-left shunt. However, this generally occurs if the VSD is allowed to persist for months to years, which is less likely in our 3-week-old infant. B. Incorrect. A widely split, fixed S2 indicates an atrial septal defect (ASD). These are often detected in children when they're between 3 and 5 years old. The systolic murmur is due to the increased blood flow across the pulmonic valve. The widely split fixed second heart sound indicates an ASD is the cause of the murmur rather than an innocent heart murmur. C. Incorrect. A continuous murmur that is louder during systole describes a patent ductus arteriosus (PDA). A PDA, like a VSD, is also discovered during infancy. However, a holosystolic murmur with a palpable thrill at the left lower sternal border is more characteristic of a VSD. The murmur of a VSD is from the left-to-right shunting of blood during systole due to systemic vascular resistance exceeding pulmonary vascular resistance. D. Correct. A heart murmur from a VSD is typically not appreciated in the immediate newborn period, as the pulmonary vascular resistance is still quite elevated. During this time, since the pulmonary vascular resistance equals the systemic vascular resistance, there is no shunting of blood through the open VSD. However, after a few days to weeks after birth, the pulmonary vascular resistance decreases, and the murmur appears, reflecting the shunted flow of blood through the open VSD (from left to right).

A 6-month-old female is brought into the pediatrician's office for three days of high fever, fussiness, and decreased appetite. The patient has not had any upper respiratory tract symptoms, vomiting, diarrhea, or rash. On physical exam the patient is fussy, has a RR of 28 bpm and a pulse of 160 bpm. She is febrile to 102.8 F (rectal). The patient is alert and fully moving all extremities. Apart from her vital signs, no other significant exam findings are noted. A CBC demonstrates leukocytosis of 17.0 cells x 103 / µL with elevated bands. What diagnosis is most likely? A Measles B Bacterial meningitis C Acute otitis media D Urinary tract infection E Roseola

D has been selected by the expert. A. Measles typically begins with a "prodrome" period featuring the "3 Cs" (cough, coryza, conjunctivitis)—none of which this patient has—along with high fever, often > 104 F, and general malaise and anorexia. On the 2nd to 4th day a maculopapular erythematous rash appears starting on the face/upper neck and spreading downward. Although infants receive their first vaccination against measles (the MMR) at 1 year of age, infants are generally protected unless they are exposed to older, unimmunized children who have the disease. B. This answer is incorrect in this situation for several reasons. First, this patient is not toxic appearing, nor is her physical exam positive for any findings suggestive of meningitis (such as bulging fontanel or extreme irritability). Unlike older children or adults, classic meningeal signs will often not be present or will be difficult to appreciate on an infant. The patient's CBC is significant for leukocytosis with elevated bands, suggesting a bacterial infection. On exam the patient is alert and responding well to her environment and does not demonstrate lethargy, respiratory distress or signs of ICP. A definitive lumbar puncture may be ordered if there is more suspicion for meningitis or if the patient's status deteriorates in any way, and caretakers should be given a follow-up appointment as well as clear indications of when to seek care. C. This answer is incorrect because while fever and fussiness can be possible signs of AOM in infants, there is no evidence of infection on physical exam such as inflamed, erythematous tympanic membranes, with bulging of the membrane indicating an effusion. D. UTI, the most common bacterial illness in a female infant, is consistent with her high fever, fussiness, and decreased appetite. Her CBC suggests that she has a bacterial infection (leukocytosis and elevated bands). A sample of her urine should be obtained by catheterization and sent for urinalysis and culture. E. Roseola often presents with a high fever, but also often with a viral prodrome. It is a diagnosis of exclusion at this point and should not preclude obtaining a urine sample in this child.

Jade is a 2-week-old female who was born at home and received no newborn screenings for congenital disease. Her mother brought her to the pediatrician's office concerned that her daughter appeared to be jaundiced and was constipated, tired, and not feeding well most of the time. Physical exam was notable for enlarged fontanels, jaundice without bruising, hypotonia without tremor or clonus, and an umbilical hernia. There was no sign of virilization, no abnormal facies, and no history of vomiting. Review of systems was otherwise negative except as stated above. Which of the following is the most important next step in Jade's management? A Glucose and electrolyte supplementation B Glucocorticoid and mineralocorticoid supplementation C No treatment needed D Consult with pediatric endocrinologist and start treatment with 10 to 15 mcg/kg/day of crushed levothyroxine in liquid, and follow up every 12 months E Empiric antibiotics after collection of blood, urine, and CSF cultures.

D has been selected by the expert. A. This choice is incorrect because this is the treatment of choice for acutely ill children with dehydration, hypoglycemia, and perhaps infants with congenital adrenal hyperplasia, not congenital hypothyroidism as is most likely in this infant. B. This is the recommended treatment for corticoid and mineralocorticoid deficiency as seen in congenital adrenal hyperplasia. Clinical evaluation of this patient does not show virilization of this female infant, commonly seen in congenital adrenal hyperplasia. C. This choice is incorrect because congenital hypothyroidism requires treatment within 2 weeks of onset of symptoms to mitigate severe brain damage and cognitive impairment. No treatment is needed for children born with hypothyroxemia of prematurity without TSH elevation. D. This choice is correct. AAP recommends this treatment regimen for infants age 0 to 6 months old. Dosing is based upon age and weight. It would also be important to consult with a pediatric endocrinologist to evaluate the short and long-term treatment plan. In addition, the specialist could also recommend screening for other autoimmune disorders. E. This choice is incorrect. Although sepsis must always be considered in a neonate with jaundice, there is no indication of bacterial infection in this infant with other signs and symptoms of congenital hypothyroidism.

A 5-year-old girl comes into your office for a well-child visit. The mother says that child is overall very healthy, but she highlights "occasional colds" and recently more frequent temper tantrums. She does well in preschool, is toilet trained, and enjoys eating mostly pasta, bread, and milk. She lives with her mother and father in a home built in 1985. Lab studies were significant for a mild anemia with a hemoglobin of 10.0 g/dL. You note that her hemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anemia? A Chronic blood loss B Lead poisoning C Chronic illness D Iron deficiency E Hemoglobinopathy

D has been selected by the expert. A. This choice is incorrect. There was no complaint of melena, and the child is overall healthy. Chronic blood loss would therefore be unlikely. B. This choice is incorrect. Risk of lead poisoning is increased in patients who live in homes built before the 1950s. Additionally, this patient does not complain of other symptoms suggestive of lead poisoning: weight loss, lethargy, vomiting, and learning difficulties. C. This choice is incorrect. The patient has no significant past medical history, and the review of systems is unremarkable. Chronic illness is unlikely. D. This choice is correct. Given the patient's age and preference for pasta and milk, the most likely cause of anemia would be iron deficiency. Treatment would include oral iron supplementation and increased dietary iron intake. E. This choice is incorrect. If she had a hemoglobinopathy, she would have been expected to have been anemic at her previous visit as well.

A 6-month-old infant arrives in the ED with a 12-hour history of poor feeding, emesis, and irritability. On exam, she is ill-appearing with T 39.2 C, P 160 bpm, R 40 bpm, BP 80/50 mmHg. CBC shows WBC 11.2, Hgb 13.5, Plt 250. Urinalysis shows > 100 WBC per hpf, positive leukocyte esterase, and positive nitrites. She has no history of prior urinary tract infection. Chest x-ray is negative. Urine and blood cultures are pending. After bringing her fever down, she was still uninterested in drinking, but her exam improved, and you were confident she did not have meningitis, so an LP was not performed. Which of the following is the best next step in management? Please select one answer. A Oral ampicillin B Oral ampicillin + gentamicin C Intravenous ciprofloxacin D Intravenous ceftriaxone E Intravenous piperacillin + tazobactam

D has been selected by the expert. A. This patient is too sick for oral treatment, so oral ampicillin would be insufficient. Also, there is rising resistance of E. Coli to ampicillin, so secondary coverage with gentamicin or some other aminoglycoside would be needed unless cultures proved the organism was sensitive to ampicillin alone. B. Although parenteral and oral treatment produce similar outcomes in high quality RCTs, this patient is ill and refuses to drink and so requires parenteral antibiotics. IV ampicillin and gentamicin could be an appropriate choice for empiric coverage. C. Ciprofloxacin could be used for complicated UTIs, but it has the potential for adverse reactions in young children so is reserved for patients > 1 year with complications such as resistant organisms or urinary tract anomalies D. This patient's presentation is suggestive of a UTI. Given the ill appearance, vital signs, and white count, Upper tract disease (pyelonephritis) should be strongly considered. A parenteral (IV/IM) third-generation cephalosporin is the best choice of those listed for pyelonephritis, given its excellent gram negative coverage (except for Pseudomonas). E. IV piperacillin + tazobactam has excellent gram negative coverage with added Pseudomonas coverage, but it is highly expensive and Pseudomonas is unlikely to be the cause of a UTI in a child who is not regularly catheterized.

A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in what order she should expect to see normal developmental changes in her daughter. Which of the following sequences is correct? A breast bud -> pubic hair -> menarche -> growth spurt B pubic hair -> breast bud -> growth spurt -> menarche C pubic hair -> menarche -> breast bud -> growth spurt D breast bud -> pubic hair -> growth spurt -> menarche E pubic hair -> breast bud -> menarche -> growth spurt

D has been selected by the expert. This choice is correct because breast buds are the first sign (10-11 years), followed by pubic hair (10-11 years), then a growth spurt (12 years), and then menarche (12-13 years). Most girls reach adult height by approximately 15 years.

A 5-year-old male comes to the clinic with a chief complaint of four days of progressively worsening fever and that has been minimally responsive to acetaminophen. The patient complains of sore throat and decreased appetite. His sister had a positive rapid strep test and is now being treated with amoxicillin. Your concern is for Group A strep. What is the next best step in management? A Start antibiotic treatment B Send blood cultures C Advise parents to give patient acetaminophen with return precautions D Rapid strep test with back-up culture if negative E Chest x-ray

D has been selected by the expert. Choice D would provide confirmation of your clinical suspicion and allow for correct diagnosis prior to empiric antibiotic treatment. A. Choice A is incorrect. Although you may empirically treat this child for infection with Group A strep, a test to diagnose infection should be done prior to initiation of antibiotics. B. Choice B is incorrect. There is no indication for a blood culture at this time. C. Choice C is incorrect. As the patient has a history of being exposed to a sick contact with Group A strep, being sent home with acetaminophen is also not sufficient because the patient has already been treated at home with acetaminophen with no improvement. E. Choice E is incorrect because there is no indication of respiratory symptoms.

A 6-year-old boy presents to the ED with three days of diffuse muscle aches and occasional chills. Today, he had a headache and abdominal pain. He reports that he does not feel hungry because he feels sick to his stomach. He denies recent cough, congestion, sore throat, joint pains, or sick contacts. His vitals are: T 101.3 F, BP 108/71 mmHg, P 110 bpm, R 28 bpm, O2 sat 100% on RA. On physical exam, you notice blanching, erythematous macules on his ankles and several petechiae on his wrists. Upon questioning, his mother says that the spots on his wrists previously looked like the spots on his ankles. His neck is supple and there is no hepatosplenomegaly or lymphadenopathy. He reports no sick contacts, but recently visited his cousins in North Carolina. What is the best next step in management? A Give acetaminophen, obtain a Monospot, write a note for activity restriction, and advise his mother to bring him back if he is unable to tolerate fluids B Perform skin scraping of macules and examine under microscope with KOH prep C Admit the patient, obtain CBC, blood and CSF cultures, and await culture results to guide antibiotic therapy D Admit the patient, obtain CBC, blood and CSF cultures, then give loading doses of doxycycline 2.2 mg/kg and ceftriaxone 100 mg/kg/day E Give acetaminophen and obtain CBC, UA, and BUN/Cr

D has been selected by the expert. iven the patient's abdominal pain, headaches, myalgias, fever, and nausea, followed by blanching erythematous macules, which may be transitioning to petechiae and purpura, this presentation is classic for RMSF. His recent travel to North Carolina also fits with the geographical distribution of RMSF. The treatment of choice is doxycycline. N. meningiditis coverage with ceftriaxone is also necessary given his rash, headaches, and fevers. A. Although infectious mononucleosis is a possibility, this presentation is concerning for Rocky Mountain Spotted Fever (RMSF). Of note is the absence of sore throat, lymphadenopathy, and hepatosplenomegaly, which suggest something other than mononucleosis. B. Scabies or a fungal infection such as tinea versicolor would not explain his fever, headache, abdominal pain, petechiae, and myalgias. For scabies, his chief complaint might be intense itching, and he might have an exposure history. C. This choice is incorrect. Given the history of fever, headache, and petechial rash, you cannot yet rule out meningitis and should give empiric antibiotics immediately. Then, once you have established a diagnosis of RMSF, treatment with doxycycline is indicated. E. This choice is incorrect. Although Henoch-Schonlein Purpura can present with abdominal pain and a rash on the lower extremities, it usually begins with petechiae and purpura rather than a blanching rash. Arthralgias are also absent.

A 2-year-old female with normal birth and developmental history presents with increased agitation and decreased arousability. Her father suffers from chronic pain secondary to a back injury, and her mother found an open container of pills on the bed. Vitals reflect bradycardia, bradypnea, hypotension, and slight hypothermia. On physical exam, she exhibits somnolence, constricted pupils, hypoactive bowel sounds, and hyporeflexia. What substance was most likely ingested? A Iron B Amitriptyline C Insecticides D Hydromorphone

D. Hydromorphone is correct. Opioids such as hydromorphone can cause respiratory depression, bradycardia, hypotension, hypothermia, constipation, nausea, vomiting, sedation, confusion, and/or miosis. A. NO. Iron toxicity tends to cause severe abdominal symptoms followed by signs of shock. The child would be at risk for coagulopathies, GI hemorrhage, and/or metabolic acidosis. B. NO. Amitriptyline is an anticholinergic medication that belongs to tricyclic antidepressant family. Anticholinergic toxicity can cause fever, dry, and flushed skin, urinary retention, hypertension, tachycardia, mydriasis, and/or decreased gastric motility. C. NO. Ingestion of insecticides, which typically are organophosphates, can induce increased lacrimation, salivation, sweating, urination, bronchorrhea, bronchospasm, muscle twitching, muscle weakness, bradycardia, miosis and blurred vision, and/or increased gastric motility.

Shock in children: def

Def: inadequate delivery of substrates and oxygen to meet metabolic needs of tissues

Quantifying proteinuria

Degree of proteinuria that warrants further diagnostic workup : - 30 mg/dL (1+) on 2 random urine specimens collected 1 week apart if urine specific gravity is < 1.015 OR - 100 mg/dL (2+) on similarly collected urine if specific gravity is >1.015. 24-hour Urine Collection (better) Normal: protein excreted < 4 mg/m2/hour Abnormal: 4-40 mg/m2/hour Nephrotic range: > 40 mg/m2/hour Urine Protein:Creatinine Ratio (easier to obtain from children than 24 hr) - urine protein/ urine creatinine - < 0.5 is normal in 6- to 24-month-olds - < 0.2 is normal in children 2+ years - > 1.0 is in suspicious range for nephrotic syndrome - > 2.5 is diagnostic for nephrotic syndrome

You have accepted a part-time tutoring job for first-year medical students. One of your students asks if you would please clarify the details of normal fetal circulation. Which of the following best describes the path of the majority of the blood that enters the right atrium? A RA > foramen ovale > LA > LV > systemic circulation B RA > RV > VSD > LV > systemic circulation C RA > RV > pulmonary circulation > LA > LV > systemic circulation D RA > RV > ductus arteriosus > LV > systemic circulatio E RA > RV > ductus arteriosus > systemic circulation

E A. Incorrect. In fetal circulation, foramen ovale connects the RA to the LA, allowing a portion of the blood to bypass the RV and the lungs. Approximately a third of the blood that enters the RA passes through this route (preferentially the most oxygenated which is then delivered to the brain and heart), leaving the majority of the blood to travel into the RV. Closure of the foramen ovale is a normal transition from fetal to extrauterine circulation. B. Incorrect. VSDs are common congenital heart defects, and are not considered a part of normal fetal circulation. They are commonly associated with other conditions such as Trisomy 13, 18, 21, and maternal SSRI use. C. Incorrect. In utero, without ventilation, the pulmonary vasculature is a high-resistance system. As such, only 8 to 10% of the blood that enters the RV flows through the circulation. D. Incorrect. The ductus arteriosus does not empty into the LV, but rather into the descending aorta. E. Correct. The majority of the fetal circulation travels this route. Approximately 90-92% of the blood that enters the RV (two-thirds of the blood that enters the RA) travels out and through the ductus arteriosus, bypassing the pulmonary circulation and the left heart, ending up in the descending aorta. This blood is perferentially less oxygenated than that which flows through the foramen ovale. Like the foramen ovale, closure of this bypass is a normal transition from intra to extrauterine life.

Joe, a previously healthy 11-month-old male with 5-day history of a "cold," is brought to the ED by mom for one day of acute worsening cough and intermittent wheezing. Per mom, the cough was initially dry but has become more "phlegmy," making it difficult for Joe to breathe, particularly when he is feeding or more active. His immunizations are up to date, and he has no known allergies. His family history is significant for a 6-year old sister who was diagnosed with asthma four years ago. On exam, Joe is afebrile, mildly tachypneic with normal O2 saturation. He has prominent nasal flaring and mild subcostal retractions. He has clear rhinorrhea but no evidence of oropharyngeal erythema. Lung exam reveals decreased breath sounds and wheezes on the right. What is the most likely diagnosis? A RSV bronchiolitis B Epiglottitis C Viral URI D Asthma E Foreign body aspiration

E has been selected by the expert. A. Bronchiolitis is a lower respiratory tract infection most commonly caused by RSV, which is characterized by bronchiolar obstruction secondary to mucus plugging, cellular debris, and edema. Patients generally present with fever and URI symptoms which progress to a worsening cough, wheezing and shortness of breath. Although this patient does have wheezing, the unilateral wheezing with decreased breath sounds is not consistent with bronchiolitis. B. Epiglottitis was commonly caused by Haemophilus influenzae type B, but can also be caused by Staph and Strep species. Patients may present with fever, dysphagia, drooling, stridor and significant respiratory distress. Patients are generally seen sitting, leaning forward with the neck hyperextended. Epiglottitis has become less common due to immunization with Hib. This diagnosis is less likely in our patient, since his immunizations are up to date, he is afebrile and not in severe respiratory distress. C. Our patient probably developed a viral URI five days ago. An upper respiratory tract infection in children can manifest as fever, rhinorrhea, cough, sore throat and myalgias, and may be accompanied by wheezing. However, our patient's ausculatation findings cannot be explained solely by a viral URI. D. Asthma is caused by inflammation of airway mucosa, mucus hypersecretion, mucosal edema and reversible bronchoconstriction. It generally presents as cough, wheezing, tachypnea and dyspnea worsened by cold air, exercise, allergies and URIs. The mainstay of treatment involves bronchodilators (beta-2 agonists) and inhaled steroids. Asthma is a possible diagnosis in Joe given the family history of asthma; however, it is less likely since he was previously healthy with no history of recurrent cough or wheezing. Furthermore, asthma does not generally present with focal wheezing as heard on Joe's lung exam. E. Given Joe's age, foreign body aspiration should always be included in the differential diagnosis for acute onset wheezing. The lung findings of asymmetric breath sounds and wheezing support this diagnosis. Foreign body in the airway can be confirmed by bilateral decubitus or inspiratory/expiratory chest films, characterized by decreased deflation on the affected side.

An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child? A Lymph node involvement is a poor prognostic factor B Prognosis of neuroblastoma is predictable C Children who are older than 12 months have a better prognosis than younger children D Favorable histology does not play a role in prognosis E Non-amplification of the n-myc gene is a favorable prognostic factor.

E has been selected by the expert. A. Due to the effectiveness of chemotherapy, neuroblastomas with lymph node involvement are still considered favorable, especially in the setting of other favorable factors, such as young age and differentiating histology. Though distant metastasis is a significant poor prognostic factor, regional lymph nodes do not significantly affect the outcome. B. Neuroblastoma has a broad spectrum of clinical courses. Some tumors may spontaneously regress, some may mature to a benign type, and yet other tumors can be very aggressive with metastases. Age plays a role in the prognosis, as most infants have a good prognosis even with disseminated disease, while infants over 18 months of age do not do as well. C. In infants less than one year of age, neuroblastoma tumors may spontaneously regress. Stage 4S neuroblastoma is a special category that is reserved for infants <12 months who have resectable primary tumors and metastases to liver, skin, and bone marrow. Overall survival is over 85 percent. D. Favorable histology is a good prognostic factor in neuroblastoma, and is based on the differentiation of the cells involved. E. Non-amplification of the n-myc gene is one of the favorable genetics in neuroblastoma.

Brian, a 5-year-old boy with swelling around both his eyes and an abdomen that looks "bigger than normal," is brought in by his mother to your preceptor's office. Mom explains that she noticed the puffy eyes and bigger belly starting the week before. It seemed to appear out of nowhere, and Brian has been completely healthy except he had a cold several days before these symptoms developed. When you ask Brian if he has noticed anything else weird, he says that his "pee-pee looks like Coca-cola," at which point his mom scowls and tells him to stop being silly. His blood pressure taken by the nurse right before entering the room is elevated. Based on the above information, which of the following does Brian likely have? A Periorbital cellulitis B Viral upper respiratory infection C Allergic conjunctivitis D Nephrotic syndrome E Acute glomerulonephritis

E has been selected by the expert. A. This choice is incorrect. Periorbital cellulitis is usually unilateral, and it would involve a history of insect bite, trauma, or bacterial infection such as sinusitis. Additionally, periorbital cellulitis, would not explain the larger-appearing abdomen or the tea-colored urine, all suggestive of acute glomerulonephritis. B. This choice is incorrect. Although URI could explain some of the bilateral periorbital edema and the "cold" preceding these current symptoms, URI in itself would not explain the distended abdomen or the darkened urine. C. This choice is incorrect. Allergic conjunctivitis would present with conjunctival injection in addition to the periorbital edema. Additionally this diagnosis would not explain the distended abdomen or darkened urine. D. This choice is incorrect. While nephrotic syndrome could explain the periorbital edema and ascites, it would not explain darkened urine. Also nephrotic syndrome is more associated with normal BP and Brian's blood pressure is elevated. ****E. Acute glomerulonephritis would explain all aspects of Brian's presentation. Disease presents with gross hematuria (which most patients describe as tea-colored or cola-colored), periorbital swelling and ascites due to hypoalbuminemia, and HTN due to intravascular fluid overload. Additionally, acute glomerulonephritis frequently follows a URI.

A 4-year-old girl with a history of type 1 diabetes mellitus was admitted to a local hospital for treatment of DKA. A few hours after the treatment, she develops grunting, irregular respirations, and has vomited twice. On exam, her left eye is pointing downward and out on straight gaze. Her diastolic blood pressure is 90 mmHg. What is a likely diagnosis? A Hypoglycemia B Hypokalemia C Hyponatremia D Pneumonia with possible sepsis E Cerebral edema

E has been selected by the expert. A. This choice is incorrect because although hypoglycemia can be a complication of DKA treatment, it would be unlikely to cause a cranial nerve palsy. B. This choice is incorrect. Although hypokalemia can be a complication of DKA treatment, it would likely present as an elevated BP, muscular weakness or myalgia, as well as muscle cramps, constipation, and hyporeflexia in severe cases, rather than with the symptoms described in this vignette. C. This choice is incorrect because, while hyponatremia can occur (due to the dilutional effect caused by water shifting from the intracellular to the extracellular compartment because of hyperglycemia and increased plasma osmolarity), it would be corrected with the DKA treatment and would not present with a cranial nerve palsy. D. This choice is incorrect because pneumonia would not present with a cranial nerve palsy, although it might be important to evaluate patients with DKA for signs of intercurrent illness, including pneumonia, UTI, and perinephric abscess. E. This choice is correct. Administration of bicarbonate during DKA treatment increases the risk of cerebral edema. Although symptomatic cerebral edema is rare (less than 1%), it is associated with a high mortality rate (over 20%). The signs of cerebral edema are described in the vignette, and include irregular respirations, headache, vomiting, third nerve palsy, and high blood pressure.

A 1-month-old African-American male presents to your office for a check-up. The baby was born at term by NSVD to a 29-year-old G1P0 mother with no complications. Mother states the baby was feeding well until a week ago, when he developed increased sleepiness, prolonged feeding, and greater duration between feeds. His mother notes he stops to take breaks sometimes because he seems to be trying to catch his breath. He has 4 to 6 wet diapers per day and poopy diapers 3 or 4 times per day. Vital signs are: T: 37.6 C, RR: 68 bpm, P: 138 bpm, BP: 88/58 mmHg, and 02 saturation is 98%. The physical examination is notable for increased respiratory effort and retractions, and, upon cardiac examination, a murmur with a hyperactive precordium and no cyanosis. Abdominal exam reveals a liver edge palpable to 4 cm below the right costal margin. Which condition would be least likely to be the cause of the patient's symptoms? A Aortic stenosis B Coarctation of the aorta C Ventricular septal defect D Patent ductus arteriosus E Atrial septal defect

E is correct because ASDs do not cause CHF. An ASD malformation is a left-to-right shunt, and—depending on the size of the defect—the patient may or may not present with symptoms. ASDs often go undiagnosed for decades due to subtle physical examination findings and/or a lack of appreciable symptoms. If the defect is large enough, pediatric patients may present with easy fatiguability, recurrent respiratory infections, or exertional dyspnea. A. Choice A is incorrect because aortic stenosis is one of the heart defects that present with a murmur and signs of CHF in infancy. An estimated 10-15% of patients with aortic valve stenosis present when they are younger than one year of age. Neonates with critical stenosis are typically symptomatic and present with symptoms of congestive heart failure—including poor feeding, rapid breathing, poor urine output, and fussiness—as the ductus arteriosus closes and systemic blood flow decreases. B. Choice B is incorrect because coarctation of the aorta is one of the heart defects that present with a murmur and signs of congestive heart failure in infancy. Pediatric patients may present in the first few weeks of life with poor feeding, tachypnea, and lethargy and progress to overt CHF and shock. Symptoms may be subtle at first, and patients may make repeated trips to the physician before being diagnosed. Presentation after the neonatal period is usually consistent with hypertension or a murmur. Patients usually have not developed overt CHF because of the presence of arterial collateral vessels. C. Choice C is incorrect because ventricular septal defect is one of the heart defects that present with a murmur and signs of congestive heart failure in infancy. Signs and symptoms often appear during the first few days, weeks, or months of a child's life. VSD is an acyanotic congenital heart defect, manifesting as a left-to-right shunt. A holosystolic murmur is often appreciated, with larger VSDs causing a parasternal heave. An infant with a large VSD will fail to thrive and become diaphoretic and tachypneic, especially with feeding. D. Choice D is incorrect because a large patent ducutus arteriosus (PDA) is one of the heart defects that present with a murmur and signs of congestive heart failure in infancy. A PDA is more common in premature infants and those with neonatal respiratory distress syndrome. A smaller PDA may not cause any symptoms, but infants can present with tachypnea, poor feeding, tachycardia, shortness of breath, fatigue, diaphoresis, and poor growth.

Follow-up Care for Kawasaki Disease

Early cardiology follow-up with a repeat echocardiogram - If coronary artery aneurysms develop, they usually do so within 4 weeks of acute illness, so a follow-up visit at 1-2 weeks is recommended.

FAS hgb

FAS means the baby is a carrier of one abnormal hemoglobin gene—for hemoglobin S. This individual has benign sickle cell trait—i.e., is a carrier of hemoglobin S.

macrocytic anemia differential

Folate deficiency B12 deficiency Liver disease Hypothyroidism Neoplasms Bone marrow failure syndromes (aplastic anemia, Diamond-Blackfan anemia [DBA], and congenital dyserythropoietic anemia [CDEA])

Benefits of breastfeeding

For Infants - Maternal-infant bonding - Protection against some infections (e.g. otitis media, respiratory infections, diarrhea) - Reduced rates of Sudden Infant Death Syndrome - Reduced rates of some allergic reactions For Mothers - Decreased postpartum bleeding and more rapid uterine involution - Lactational amenorrhea and delayed resumption of ovulation with increased child spacing - Earlier return to pre-pregnant weight (compared with women who formula-feed) - Improved bone remineralization postpartum with reduction in hip fractures in the postmenopausal period - Decreased cost, relative to formula - Ready availability without preparation time

Stages of puberty: female

Girls start puberty between 8 and 13 years of age 1) Breast buds appear (age 10-11 years), then, 2) Pubic hair appears (age 10-11 years) then, 3) Growth spurt (age 12 years), 4) Periods begin/menarche (age 12-13 years) 5) Attainment of adult height (age 15 years)

Physiologic effects of opioid drug ingestion

HR depressed BP depressed RR depressed Hypothermia Constricted Hypoactive abd

Physiologic effects of sympathomimetic drug ingestion

HR, RR, BP elevated Hyperthermia Diaphoretic Dilated Hyperreflexia Hyperactive abd

First and second hour of life HR and RR

HR: 160-180 per minute -> 120-160 per min RR: 60-80 per minute -.> 40-60 per min

most commonly diagnosed form of vasculitis in children (about 50% of cases)

HSP

Backwash ileitis

Ileal inflammation in UC from inflammation in colon

Core symptoms of ADHD

Inattention, hyperactivity, impulsivity

Bulging fontanel

Increased intracranial pressure, as may be seen in: - Meningitis - Hydrocephalus - Subdural hematoma - Lead poisoning

Causes of chronic cough (5)

Infection Inflammation Irritation Anatomic Psychogenic

What GI problem causes unresponsiveness in children?

Intussiception when really bad

Testing for down syndrome standard

LYMPHOCYTE karyotype remains standard for laboratory diagnosis of Down syndrome.

Single greatest barrier to health care access for children of Latino parents

Language

Most sensitive and specific lab test for dx of pancreatitis?

Lipase

Wet cough cause

Lower resp infection

most common manifestation of nontuberculous mycobacteria in children, with a peak age of presentation of 2 to 4 years

Lymphadenitis

Which psychiatric condition has the highest comorbidity with ADHD?

ODD/CD

Most common form of nephrotic syndrome in children?

Minimal change disease - 90 % of cases <10. - characteristic histologic finding: FUSION and diffuse EFFACEMENT of EPITHELIAL CELL FOOT PROCESSES on electron microscopy. - nephron appears normal on light microscopy.

Opioid OD symptoms

Miosis (constricted pupils) Respiratory depression Bradycardia Hypotension Hypothermia Depressed mental status (sedation, confusion, coma)

???Do hemoglobinopathies cause jaundice?

No

Does erythromycin help prevent chlamydia trachomatis?

No - more common than gonococcal, but typically occurs at 7-14 days after birth

Can you give OTC antihistamines to a child <2 yrs of age?

No!

ECG findings in patient with small VSD

Normal

Germ cell tumor locations (2)

Pineal Suprasellar

Prochaska's model for stages of change

Pre-contemplation: Patient: "Problem? What problem?" The physician's role is to provide advice and information to help the patient develop an awareness of the need for change. C ontemplation: Patient is ambivalent; sees the need for change, but rationalizes why change is either not possible or desirable. Physician's role is to recognize the ambivalence, to support motivating factors and help alleviate barriers to change. Determination: Patient: "I must change; I can do it." At this stage, the patient is "talking the talk." Physician helps to design a plan and problem-solve. Action: Patient: "What can I do? Who can help?" Here, patient is "walking the walk." Physician reinforces action, helps to anticipate and deal with withdrawal. Maintenance: Patient feels satisfaction; patient may reinforce this stage by being a role model for others. Relapse: Patient feels loss of control, demoralization. Physician needs to be available for support, identify antecedents of relapse, help patient re-enter pathway for change above. One of the most frequent reasons for failure to change, according to this model, is a disconnect between patient and physician. Most physicians are already at the Determination/Action stage, whereas the patient may not yet be. Making a plan for change is inappropriate for a Pre-contemplative patient. A plan that is too hard may serve only as another reason for a Contemplative patient to avoid change.

Screening guidelines for T2DM

Risk criteria - Overweight (i.e., BMI > 85th percentile; weight:height > 85th percentile; or weight > 120% ideal for height) PLUS any two of the following risk factors: -FHx of Type 2 DM in first- or second-degree relative - Race/ethnicity (Native American, African-American, Hispanic American, Asian/South Pacific Islander) - Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, polycystic ovary syndrome, hypertension, dyslipidemia) - Maternal history of diabetes or gestational diabetes during the child's gestation Age of initiation of screening - 10 years of age or at onset of puberty, whichever is earlier Screen every 3 years

Edwards syndrome

Severe intellectual disability Prominent occiput Micrognathia Low-set ears Short neck Overlapping fingers Heart defects Renal malformations Limited hip abduction Rocker-bottom feet

What tx makes tinea infection worse?

Steroid creams

Strawberry tongue possible causes (3)

Streptococcal pharyngitis Kawasaki disease Toxic shock syndrome

most common cause of mycobacterial lymphadenitis in children over 12 years of age.

TB Children with these infections usually appear well with minimal if any constitutional signs and symptoms.

Decreased risk for hyperbilirubinemia

TSB or TcB level in the low-risk zone Gestational age 41 week Exclusive bottle feeding Black race Discharge from hospital after 72 hours

Most common heart defect causing cyanosis in NEWBORN

Truncus arteriosus

Follow-up Studies for Episode of Pyelonephritis in an infant

US study of kidneys and bladder: - see renal structure and dilatations in collecting system - replaced IVP - Unless illness is of unusual severity, or child is not improving on antibiotics, the ultrasound may be obtained at completion of the antibiotic course. - Renal technetium scan:Provides evidence of pyelonephritis Not required in a patient who has responded well to treatment

Voiding Patterns in the Newborn

Urination changes in first days after birth: - Day 3: 3-4 times a day. - Day 6: 6-8 times a day. - Urine should be pale yellow.

Differential diagnosis of a 6month old with high fever and tachycardia

Viral upper respiratory tract infection Bacterial meningitis Viral meningitis Urinary tract infection Pneumonia Acute gastroenteritis Otitis media Herpes simplex virus gingivostomatitis Occult bacteremia Roseola Sepsis / bacteremia Bone / joint infection Soft tissue infection

Beckwith-Wiedemann

Wilm's tumor omphalocele hemihypertrophy hypoglycemia large for gestational age, and other dysmorphic features.

CXR: Neonatal pneumonia

X-ray findings of pneumonia may appear similar to those of an infant with TTN, but the clinical findings would be much more concerning for sepsis.

Can migraines lead to ataxia?

Yes basilar migraines

When do you make a decision about surgery in patient with VSD

at 6 months

When infection of the urine must be ruled out in an infant or child who is not toilet-trained...

catheterization.

Late sign of shock in child

hypotension

Unequal pupils is a sign of...

increased ICP

most sensitive asthma diagnostic test

spirometry Note: Bronchoprovocation with methacholine, histamine or exercise challenge is reserved for cases in which asthma is suspected and spirometry is normal or near normal, and should be performed by trained individuals.