peds EOR

What kind of anemia is associated with Mycoplasma pneumoniae?

Answer: Hemolytic anemia secondary to cold agglutinins.

What is the most common dose of dexamethasone (IM or IV) given for the treatment of croup?

A single dose of 0.6 mg/kg.

What is the EMG finding in Guillain-Barré?

Acute denervation of the muscle.

What condition should be suspected in a dehydrated neonate with hyperkalemic, hyponatremic metabolic alkalosis?

Adrenal crisis.

What other diagnoses are more common amongst children with eczema?

Allergic rhinitis, asthma, and food allergies.

What medication (and dose) can be used to temporarily preserve patency of the ductus arteriosus?

Alprostadil (prostaglandin E1), 0.05-0.1 mcg/kg/min intravenously.

Why is phimosis less common as patients age?

At birth, only 4% of boys have a fully retractable foreskin. Physiologic changes increase this rate until 4 years of age when 90% are fully retractable

What is the mechanism of thrombocytopenia in idiopathic thrombocytopenic purpura?

Autoantibodies directed against platelets lead to platelet destruction.

Failure to treat slipped capital femoral epiphysis can lead to what complication?

Avascular necrosis.

A 30-month-old boy presents with respiratory distress. He was diagnosed with croup one week ago and received a single dose of dexamethasone. His cough had nearly resolved until yesterday, when coughing worsened, and he developed nasal congestion. This evening, he developed inspiratory stridor, increased work of breathing, and a fever to 103°F. What is the most likely diagnosis?

Bacterial tracheitis (**It may occur in isolation or following a viral respiratory illness, including croup. Bacterial tracheitis should be suspected in any child with clinical worsening after improvement of croup symptoms. In children without a preceding illness, symptom onset may begin insidiously with one to three days)

What medical procedure puts uncircumcised boys at risk for developing paraphimosis?

Catheterization of the urethra during for which the foreskin has to be retracted.

What complications can arise from viral croup?

Complications can include dehydration, otitis media, and pneumonia.

What are considered confirmatory tests of group A streptococcal infection when evaluating a child with possible rheumatic fever?

Confirmatory testing may be either a positive throat culture, positive rapid antigen test, or rising streptococcal antibody titer (ASO).

Which medical treatment is known to be beneficial in patients with croup by decreasing edema in the laryngeal mucosa?

Corticosteroids.

What chronic conditions predispose infants to chronic candidal diaper dermatitis?

Diabetes mellitus type 1, chronic mucocutaneous candidiasis, or immunodeficiency.

What is the most common cause of neonatal hemorrhage?

Failure to administer vitamin K in the immediate postpartum period (associated with home births).

What are the three types of botulism infection?

Foodborne botulism, wound botulism and infant botulism.

A 16-year-old girl is seen in clinic due to vaginal discharge. She complains of gray discharge with a fishy odor. She is sexually active for the past six months and has had one partner. She uses an intrauterine device for contraception. On physical exam you note gray vaginal discharge with a vaginal pH of 5. You then perform a wet mount which shows clue cells. What is the most likely etiologic agent?

Gardnerella vaginalis. (**tx - Metronidazole or clindamycin can be used orally or intravaginally.)

What is the microscopic appearance of Neisseria gonorrhoeae?

Gram negative intracellular diplococci, or "kissing cocci."

What pulmonary sequela may occur with dengue fever?

Increased capillary permeability allows pleural effusions to form as a sequela

What viral infection is known to greatly increase the susceptibility to bacterial tracheitis?

Influenza A.

What specific gastrointestinal disorder is associated with Henoch-Schönlein purpura?

Intussusception.

Which anemia often precedes lead toxicity?

Iron deficiency anemia due to its association with pica.

What are the risk factors for development of bronchiolitis?

Male gender, lack of breast-feeding, those living in crowded conditions, maternal smoking, preterm birth, and chronic lung disease.

What is the most concerning differential diagnosis for a febrile seizure?

Meningitis. (** Patients at greatest risk for meningitis are those under 18 months, those with a focal or prolonged seizure, a seizure in the ED, or who have seen a physician within the prior 48 hours.)

What is the most common type of atrial septal defect?

Ostium secundum (75% of all cases), in which there is incomplete adhesion between the foramen ovale flap and the septum secundum.

Renal agenesis, another congenital genitourinary anomaly, presents with which fetal symptoms?

Oligohydramnios, pulmonary hypoplasia and facial abnormalities. Fetal demise is common.

What is the most common clinical manifestation of Kawasaki disease aside from fever?

Oral mucous membrane changes.

Children with hereditary spherocytosis are at risk for aplastic crisis as result of an infection from which virus?

Parvovirus B19.

What is the most common physical finding in Osgood-Schlatter?

Point tenderness on palpation of the tibial tuberosity.

What nerve distributions are affected by a Nevus of Ito?

Posterior supraclavicular and lateral brachiocutaneous nerves.

What sexually transmitted infection can present with a rash similar to pityriasis rosea?

Secondary syphilis.

Which medications are recommended for treating WPW during pregnancy?

Sotalol or flecainide.

What is the most common organism associated with bacterial tracheitis?

Staphylococcus aureus.

What radiographic sign is present in both croup and bacterial tracheitis?

Steeple sign.

What is the most common cause of meningitis in adult patients?

Streptococcus pneumoniae.

What is the classic radiographic abnormality seen in aortic coarctation?

The "figure-3" sign, characterized by prestenotic aortic dilation, coarctation indentation and poststenotic aortic dilation.

What ligament gets displaced during a radial head subluxation?

The annular ligament

n: What is the treatment for absence seizure

The most common medications used are ethosuximide and valproic acid.

At what ages is the DTaP vaccine recommended?

Two months, four months, six months, 15 to 18 months and four to six years.

A 5-year-old boy presents with abdominal pain, grogginess and vomiting. His father states his son's stools have had a jelly-like appearance for the past 36 hours. You appreciate a sausage-shaped mass during abdominal palpation. Which of the following diagnostic tests is the most appropriate during this child's diagnostic evaluation?

US (**intussessception)

What is the initial study of choice for a patient with acute testicular pain?

Ultrasound with Doppler.

What is the most common cause of treatable subfertility in men?

Varicocele; present in 15% of men. This can be treated with Varicocelectomy.

Which vitamin abnormality is associated with pseudotumor cerebri?

Vitamin A deficiency or hypervitaminosis A.

A 3-week-old boy presents with non-bilious, forceful emesis for 2 days. On examination, the infant appears active and feeds vigorously followed immediately by vomiting. what is the most appropriate diagnostic study?

abdominal us

A 3-year-old girl is brought to the urgent care clinic for a 4-hour history of dysphagia, fever, drooling, and difficulty breathing. She is in acute distress, restless, and irritable. Her immunizations are up to date. Her temperature is 40.0°C (104°F). Auscultation of the lungs reveals inspiratory stridor. what is the most likely diagnosis?

acute epiglotittis

What common viral infection is associated with intussusception?

adenovirus

A two-year-old previously healthy boy is witnessed having a tonic-clonic seizure in the emergency room. Mom originally brought him in due to a fever of 39°C. The episode lasted five minutes, and the patient returned to baseline mental status. what is the most appropriate next step in management?

administer antipyretics (** simple febrile seizure )

9 year old boy presents to ED w/ cc of bizarre behavior & intermittent fevers for the past week and is now complaining of joint pain and swelling. mom noticed writhing, purposeless, and uncontrollable movements of her son's hands. on PE, On exam, a diastolic murmur is noted at the right upper sternal border. what diagnostic test is most likely to confirm the dx?

antistreptolysin O ( ASO titer )/ rapid strep test/positive throat culture (**pt has acute rheumatic fever...remember the Jones criteria)

A 2-week-old baby boy is brought to clinic for routine care by his mother who is concerned about sudden infant death syndrome. Which of the following is a level A recommendation from the American Academy of Pediatrics to help reduce the risk of sudden infant death syndrome? A Cardiorespiratory monitoring when the baby is sleeping B Offering a pacifier at naptime and bedtime C. padded crib bumpers D side sleep position

b

: What is the most common complication associated with chicken pox?

bacterial infection of skin lesions

A 23-year-old woman delivers her first child. Her family history is positive for three uncles who needed early-in-life surgery for "heart defects." You are asked to assess her 1-day-old infant who does not "appear well" according to the nursing staff. During your examination, which of the following findings most suggests the presence of congenital heart disease?

basilar crackles and peripheral edema. (signs of CHF) Congenital cardiac defects occur in 8 out of 1000 live births. Up to one third of infants born with a congenital cardiac defect develop life-threatening symptoms within the first few days of life, with 80% of infants presenting with congestive heart failure (pulmonary or peripheral edema or both). The mortality rate in this critical period is 90%. The majority of these defects can be screened for in the prenatal period with four-chamber echocardiography. Consider screening in women with diabetes, a family history of congenital heart disease, indomethacin exposure or rubella exposure.

A 12-year-old girl presents for her annual well child check. She had menarche eight months prior, and has had menses every month. Each cycle lasts two weeks. The patient uses at least six pads on most days of the cycle. On exam, she is pale but otherwise well appearing. Her heart rate is 80 beats per minute, blood pressure 110/65, and respiratory rate 14. The remainder of her exam is within normal limits. Which of the following are the most likely laboratory findings? A. Hemoglobin 12 g/dL, mean corpuscular volume 80, RDW 10 B. Hemoglobin 6 g/dL, mean corpuscular volume 60, RDW 12 C. Hemoglobin 6 g/dL, mean corpuscular volume 60, RDW 18 D. Hemoglobin 8 g/dL, mean corpuscular volume 100, RDW 10

c This patient has iron deficiency anemia secondary to dysfunctional uterine bleeding. Iron deficiency anemia is characterized by a microcytic anemia (low hemoglobin and low MCV). Approximately two percent of adolescent females experience iron deficiency anemia due to menstrual blood loss and the adolescent growth spurt. Most children with iron deficiency anemia are asymptomatic. The most common sign is pallor, which usually does not occur until the hemoglobin level is < 8 g/dL. Iron studies in this patient show reduced iron stores (low ferritin), increased iron-binding capacity (high transferrin and elevated TIBC), and decreased transferrin saturation. The mean corpuscular volume (MCV) describes red blood cells as microcytic, normocytic, or macrocytic. A normal MCV in an adolescent female is approximately 80. The red cell distribution width (RDW) is a measure of the variability in size of red blood cells. Iron deficiency anemia is characterized by an elevated RDW (11.5-14.5).

A 3-day-old neonate is brought to clinic with copious eye discharge and eyelid swelling bilaterally. Her mother received minimal prenatal care and delivered the neonate at home. Which of the following is indicated?

ceftriaxone IV

3-year-old boy is brought to the urgent care clinic by his mother. She tells you he has had a fever and cough for the past 2 days. His temperature is 38.6°C (101.5°F) and his respiratory rate is 35/min. Auscultation of the lungs reveals inspiratory stridor with a prolonged inspiratory phase. A chest X-ray shows subglottic narrowing. what is the most likely the best treatment for this child's condition?

corticosteroids (** for croup )

17-month-old girl presents to the office with two days of fever, congestion, and cough. On examination, inspiratory stridor is noted when the patient becomes fussy. What is the most likely etiology of her stridor?

croup

Which of the following statements is true regarding febrile seizures? A Administering acetaminophen and ibuprofen during a febrile illness have been shown to decrease the likelihood of seizure recurrence B Children who have had a simple febrile seizure have the same rate of epilepsy as those who have not had a febrile seizure C Older children with a febrile seizure are more likely to have a recurrence than younger children with a febrile seizure are D Treatment with long-term anticonvulsants does not lower the long-term risk of developing epilepsy

d

An 18-month-old boy is brought in by his parents for shortness of breath. The parents woke to him coughing a low-pitched cough. They also noted other noises when he was breathing in that resolved upon walking outside. The patient is frequently coughing but has no abnormal sounds on auscultation of the neck or lungs. What is the most appropriate treatment?

dexamethasone (**croup)

A 9-year-old boy presents with an inability to retract his foreskin. He has not been able to urinate for 2 days. The visible portion of the glans appears dusky. what tx is most appropriate?

dorsal slit procedure (**This patient presents with phimosis and evidence of vascular compromise requiring performance of a dorsal slit procedure. Phimosis occurs when the foreskin of an uncircumcised penis becomes constricted preventing retraction of the prepuce from the glans. It results in urinary outlet obstruction, glans ischemia and infarction. Many cases are physiologic resulting from normal development. Patients typically present with an unretractable foreskin and symptoms consistent with urinary obstruction including decreased urinary stream. Management of phimosis can be difficult. Dilation of the prepuce can be performed using forceps but often does not result in relief of phimosis. When there are signs of glans vascular compromise (i.e. discoloration) a dorsal split procedure should be performed. During this procedure, the foreskin is anesthetized and incised dorsally allowing for retraction.)

A 4-month-old baby presents to your office with symptoms of worsening constipation, poor feeding, listlessness, and generalized weakness for two weeks. Physical exam findings include temperature of 98.6°F, ptosis, poor head control and poor ability to suck. what is the most appropriate initial therapy?

human derived botulism immune globulin

The typical flow of blood across an atrial septal defect occurs in what direction?

left to right atria

Which antiepileptic medication can cause hirsutism and gingival hyperplasia?

phenytoin

What are three contraindications to receiving the MMR vaccine?

pregnancy, immunocompromised individuals, and advanced malignancy.

The athlete who suffers multiple concussions and returns to play too soon is at risk for what syndrome?

second impact syndrome

A 15-year-old boy is sent to you by the athletic trainer of the local football team after suffering his 3rd concussion of the season. Based on current guidelines, your advice pertaining to this patient returning to play should be when?

shouldn't play for rest of season (**A concussion, also known as mild traumatic brain injury (MTBI), is defined as an alteration in cerebral function secondary to a direct or indirect force on the brain. Current guidelines state that after an athlete's 3rd concussion, he or she should terminate the current season but may return to play the subsequent season if asymptomatic.)

A two-year-old child is seen in the emergency room with recent onset of cough and progressive stridor. Respiratory cultures are taken, and you are concerned for bacterial tracheitis. What is the most common organism isolated on respiratory cultures in bacterial tracheitis?

staph aureus

A mother brings her full-term 3-day-old male to the ED after she noticed an episode of dark, tarry stool at home. Mom delivered the newborn vaginally with no complications. Mom is a vegan and is breastfeeding. On exam, the patient is afebrile. His abdomen is soft with no palpable masses. Rectal exam reveals dark, tarry stool that is guaiac positive. what is the most likely cause of this patient's presentation?

swallowed maternal blood (**In the neonatal period, the most likely cause of lower gastrointestinal bleeding is swallowed maternal blood, from either delivery or cracked nipples during breast-feeding. The Apt test differentiates fetal from maternal blood. The blood in question is mixed with alkali to detect conversion of oxyhemoglobin to hematin. Fetal hemoglobin is more resistant to denaturation than adult hemoglobin is. If the supernatant stays pink after addition of alkali, the blood is fetal in origin (a positive test). This should not be confused with the Kleihauer-Betke test, used to detect fetal-maternal hemorrhage in the pregnant female.)

A newborn is being evaluated for cyanosis. Physical examination shows a prominent right ventricular impulse, a systolic thrill, and clubbing of the fingers and toes. A crescendo-decrescendo murmur with a harsh systolic ejection quality is heard along the left upper sternal border. dx?

tetralogy of fallot

A 4-month-old infant presents with erythematous plaques to the bilateral cheeks that have been worsening over the past three weeks. Similar plaques are noted over both elbow extensors. He has been growing and developing normally. What is the treatment of choice?

topical emollients (**Thick, unscented creams and ointments and preferred to lotions. Emollients should be applied at least twice per day and re-applied after bathing, swimming, or hand-washing. If the eczema is persistent, a topical steroid may be applied in addition to topical emollients. The lowest effective potency of corticosteroid should be prescribed, and steroids should be applied only to affected skin to avoid the side effects of skin thinning, atrophy, and telangectasias. Desonide or hydrocortisone are good initial low-potency topical corticosteroids.)

A 12-month-old girl presents with recurrent urinary tract infections. The external genital examination is normal. Renal ultrasonography shows hydronephrosis. Voiding cystourethrography does not reveal any detrusor abnormality.what is the most likely diagnosis?

vesicoureteral reflux (VUR), congenital abnormality of ureterovesicular junction, particularly a defect in the normal flap-valve mechanism in the intramural ureteral canal. An upper tract bacterial infection is a common result. Over time, recurrent kidney infections can lead to renal scarring, dysfunction and systemic hypertension in the adult population. Diagnosis is made by ultrasonography and voiding cystourethrography (VCUG). Symptoms may resolve spontaneously over months to years. Treatment may include prophylactic antibiotics and ureteral re-implantation.

An 8-month-old boy fails to obtain age-appropriate milestones. His mother feels that he is too fatigued to properly feed. An echocardiogram reveals a large atrial septal defect. what physical examination abnormalities would you most expect to find in this infant?

widely split and fixed S2

Is home monitoring recommended for patients with a history of severe BRUE?

yes, Unlike in SIDS, where monitoring plays no role, home monitoring is recommended for use in patients with severe BRUE.

What are the treatments of choice for Osgood-Schlatter disease and Patellar tendonitis?

Self-limited and can be treated with rest, ice and NSAIDs.

What is the mechanism of action of vancomycin?

It inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor.

Which virus most commonly causes croup?

Parainfluenza virus.

What are the four cardiac anatomical abnormalities in tetralogy of Fallot?

Pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy.

An eight-year-old boy presents to your office with complaints of fever, headache, and rash. His mother tells you that he recently returned from visiting relatives in North Carolina. Physical exam reveals a maculopapular rash on the patient's wrists and ankles that appears to be spreading to his trunk. His temperature is 102°F (38.9°C). what is the most appropriate therapy?

doxycycline (**patient has rocky mountain spotted fever: he classic triad of headache, fever, and a rash is seen in most patients by the second week of infection. Patients may also present with myalgias, central nervous system symptoms such as confusion and lethargy, or gastrointestinal symptoms such as nausea, vomiting, diarrhea, or abdominal pain. RMSF is a clinical diagnosis made when exposure to ticks is determined.)

two-month-old infant presents with two weeks of nasal congestion and cough. Over the past two days, the cough has acutely worsened. Her family describes discrete episodes of coughing and gagging, sometimes followed by emesis. She appears well between coughing episodes. What treatment is indicated?

oral Azithromycin (**drug of choice for rapidly eradicating B. pertussis from the nasopharynx. Its dosing is 10 mg/kg for five days)

What feature of tetralogy of Fallot determines the prognosis?

Answer: The prognosis of tetralogy of Fallot depends on the severity of right ventricular outflow tract obstruction

What is Dance's sign?

Considered pathognomonic for intussusception: a sausage-like mass in the RUQ representing the actual intussusceptum and an empty space in the RLQ representing the movement of the cecum out of its normal position.

A two-month-old boy is sent to the emergency department by his pediatrician for cough and an abnormal CBC with lymphocytosis. He is up-to-date with immunizations. His older brother, who is four years old, is not up-to-date since the pediatrician suspended his immunizations due to a developing neurologic condition. The brother has also had a febrile illness and has been coughing for more than three weeks. You observe the two-month-old coughing and see a period of peri-oral cyanosis. What is the most sensitive and specific method of confirming your suspected diagnosis?

PCR of nasopharyngeal secretions (** to dx pertussis/whooping cough)

7-year-old boy presents complaining of occasional intermittent lower abdominal pain over the last several weeks associated with a decline in the frequency of bowel movements to one every third day. When he does defecate, stools are hard to pass and sometimes painful. There is no blood in the stools. He has no chronic medical problems, has never had surgery, and takes no medications. Review of systems are negative and physical exam is normal. What is the most appropriate initial intervention for this child?

Polyethylene glycol is an osmotic laxative, and reasonable first line oral medication to use for maintenance therapy of constipation, defined as a two week history or more of delay or difficulty in defecation. Other options include magnesium hydroxide, lactulose and sorbitol. The most common cause of constipation in children is functional constipation, meaning constipation without objective evidence of a pathological condition. Behavioral modification including unhurried time on the toilet after meals to discourage withholding of stool, as well as feeding children a diet of whole grains, fruits and vegetables is recommended as part of the treatment of constipation, though studies suggest that medication is often necessary to achieve regular bowel movements. Fever, abdominal distension, anorexia, nausea, vomiting, weight loss, or poor weight gain suggest a more serious etiology and should prompt further work-up with imaging and laboratory studies.

What signs on chest X-ray signify ingestion of a button battery?

The double-rim or halo-effect.

What happens to the C3 and C4 complement levels in serum sickness?

They are markedly decreased

5 year old boy with cc of limp with fever and bone pain for 2 weeks and trouble walking for last 2 days. on PE, note multiple inguinal nodes that are nontender, firm, rubery, and 20 mm in diameter . no evidence of. point tenderness. Labs show anemia, thrombocytopenia, and neutropenia. lymphoblasts seen on blood smear. dx?

acute lymphocytic leukemia (** peak incidence from 2-5 years old)

A 12-year-old boy with Wolff-Parkinson-White syndrome presents with palpitations for the past hour. His blood pressure is 110/62 mm Hg and pulse is 166 bpm. The ECG reveals a narrow-complex tachycardia. Vagal maneuvers are ineffective. what is the next most appropriate management?

adenosine (**Wolff-Parkinson-White syndrome is a congenital cardiac defect in which an abnormal conduction pathway exists between the atria and the ventricles. It is commonly accompanied by congenital cardiomyopathy. Infantile or childhood onset of paroxysmal tachycardia is the typical manifestation. These appear as a narrow complex tachycardia and referred to as orthodromic. In orthodromic tachycardia, the normal pathway is used for ventricular depolarization, and the accessory pathway (bundle of Kent) is used for the retrograde conduction essential for reentry. Management begins with vagal maneuvers. If unsuccessful and the patient is hemodynamically stable, AV nodal blocking agents, such as adenosine or calcium channel blockers, can be administered.)

A father brings his 2-week-old newborn to the ED after a gagging episode at home where the infant "turned blue." The newborn was sleeping in his father's arms when he started choking, turned blue, and went limp. The father turned the baby over, did 5 back blows, and performed CPR for 5 minutes until the newborn started crying. On exam, the newborn appears sleepy but is easily arousable. Vital signs are HR 160, RR 30, T 37.6°C, and pulse ox is 99% on room air. what is the next best step in management?

admit to hospital for further work up.

A 10-year-old boy presents to your office with complaints of fever, malaise, and facial swelling that began four days ago. He is not up-to-date on his immunizations. Physical examination reveals a temperature of 99.8OF and enlarged parotid glands. Which of the following is the most appropriate therapy?

ibuprofen (mumps) mumps: Mumps is an acute viral illness caused by rubulavirus. Prior to the development of the MMR (measles, mumps, rubella) vaccine, mumps commonly affects grade school-aged children. Cases have decreased significantly due to a widespread vaccination program, although sporadic outbreaks can occur. Infection with the virus causes low-grade fever, headache, malaise, and swelling of bilateral salivary glands, typically the parotid glands. Diagnosis is based on the presence of parotiditis, along with a history suggestive of mumps. The course of illness is self-limited, with treatment being supportive measures, including ibuprofen or acetaminophen. Prevention of illness is through immunization with the mumps vaccine. Viral meningitis and unilateral acquired sensorineural deafness were the most common sequelae.

What is seen on electron microscopy of the glomerulus in patients with poststreptococcal glomerulonephritis?

immune deposits in the subepithelial space

What is the most common causative organism of meningitis in a 1-week-old child?

group b strep (Group B Streptococci (GBS) is the most common causative pathogen for meningitis in neonates. There are many bacteria that can cause meningitis. The most likely causative organism changes based on host factors including age, comorbidities and immune status. It is important to know the most common causes in different patient groups in order to tailor antibiotic regimens. In neonates, group B streptococci account for more than 75% of cases of meningitis. Other common organisms include Streptococcus pneumoniae, Neisseria meningitides and Listeria monocytogenes. GBS is transmitted from the mother during childbirth. As such, rates of GBS have fallen with the wide spread practice of intrapartum prophylaxis. Neonates with meningitis will present nonspecifically with behavioral changes, neurologic changes and vital sign abnormalities. Because of the nonspecific presentations all neonates with a fever should be considered for lumbar puncture to rule out the diagnosis.)

A 3-week-old infant presents with projectile vomiting. Mom reports he has vomited after each feed for the last 24 hours. What electrolyte abnormality do you expect to see?

hypochloremic, hypokalemic, metabolic alkalosis (**patient has hypertrophic pyloric stenosis)

A 2-year-old girl presents to the emergency department for ingestion of a penny. An older brother witnessed the event at 5:00 pm. She is currently asymptomatic. A chest X-ray at 7:00 pm shows a round radiopaque object in the mid esophagus. Other than keeping the child from eating, what is the next step in management? a. Encourage the patient to drink water to push the coin into the stomach b.Immediately remove the object endoscopically c.Induce vomiting with syrup of ipecac d . repeat chest xray in 4 hours

d (**About 90% of blunt objects ingested by children pass through without intervention. Ingestions of blunt objects can be observed for 24 hours after which time it should be removed if it has failed to pass through the stomach. If the object passes through the stomach, the patient can be observed for another week without intervention. )

A three-year-old girl presents with headache, fatigue, anorexia, and myalgias after returning from a trip to the Dominican Republic. You notice multiple mosquito bites on physical examination. You suspect dengue fever. What is the treatment of choice for this diagnosis?

supportive care

Where are the beta cells located in the pancreas?

The islets of Langerhans.

What are the cutaneous side effects of topical corticosteroid applied to normal skin?

Thinning, atrophy, telangectasias, purpura, and hypertrichosis.

How can purpura be differentiated from ecchymoses?

Purpura do not blanch under pressure.

A 10-year-old child presents for a well child check. He is currently living in a shelter with his family. A tuberculin skin test is placed subcutaneously. what is the minimum criteria for a positive test in 48 hours?

10 mm diameter of induration or greater.

What is the treatment of choice for trichomoniasis?

Metronidazole.

What is Eisenmenger syndrome?

A septal defect leading to pulmonary arterial hypertension, causing a right-to-left shunt, bypassing the lungs and resulting in cyanosis and clubbing.

A ten-year-old girl presents with drooping eyelids for the past month. The patient reports some difficulty completing her schoolwork due to blurry vision and hand weakness. On initial observation, her exam is notable for bilateral ptosis. dx?

Antibodies to the acetylcholine receptor are the most common cause of myasthenia gravis. Myasthenia gravis is a chronic, autoimmune disease characterized by fatigue of striated muscle. The first clinical signs are ptosis or extraocular muscle weakness or both. Later symptoms include bulbar muscle weakness, limb-girdle weakness, and hand weakness. This disease is notable for the rapid fatigue of muscles, which may be demonstrated by sustaining an upward gaze for 30-90 seconds or repetitive opening and closing of the fists. Symptoms increase throughout the day. Myasthenia gravis is a progressive disease and may be fatal due to respiratory muscle compromise or aspiration. A clinical diagnosis may be made with the administration of edrophonium chloride (Tensilon test), which causes immediate improvement in the ptosis and ophthalmoplegia. In infants, Neostigmine should be used to make the diagnosis, as edrophonium has increased risk of cardiac dysrhythmias in infants. Cholinesterase inhibitors are the first line of therapy. Plasmapheresis and IVIG, as well as thymectomy, can be used in refractory cases.

A 12-year-old previously healthy adolescent presents to clinic with one week of cough and fatigue. He has also developed intermittent fevers with a Tmax of 101°F. His cough and fatigue have been progressively worsening. Breath sounds are coarse throughout all lung fields. What is the treatment of choice?

Azithromycin (**atypical pneumonia aka walking pneumo) ** Mycoplasma pneumoniae and Chlamydia pneumoniae. Atypical bacterial pneumonia, also known as "walking pneumonia," has a more gradual onset and indolent course than typical bacterial pathogens such as Streptococcus pneumoniae. Symptoms of atypical bacterial pneumonia often begin with generalized malaise and progress to cough and fever. Breath sounds may be diffusely coarse and include scattered crackles or wheezes, but focal findings are typically not present. Chest film is likely to reveal perihilar and interstitial infiltrates. The treatment of choice for atypical bacterial pneumonia is five days of azithromycin. Tetracyclines may also be used in rare cases of azithromycin allergy.)

Which form of supplemental iron is most easily absorbed?

Ferrous sulfate.

What is the most common cause of lower intestinal obstruction in neonates?

Hirschsprung Disease.

What is a common side effect of ceftriaxone in neonates?

Hyperbilirubinemia.

A 6-year-old boy is brought in by his mother because his teachers noticed that he frequently tends to stare off while doing his schoolwork and will not respond to their questions. His mother states that she has seen him stare off during dinnertime but assumed that he was just ignoring her. What is your next step in the evaluation of this child?

EEG (absence seizure) his patient is having absence seizures (petit mal) and requires an EEG. Absence seizures are characterized by sudden-onset staring spells, usually lasting approximately 10 seconds, with immediate recovery. Clinically, patients may experience eye fluttering or altered postural tone that may occur many times per day. The diagnosis is confirmed by EEG, which shows characteristic generalized 3 Hz spike-and-wave discharges. Childhood absence epilepsy is an idiopathic generalized epilepsy that has an onset between 4 and 14 years of age with a peak at 5 to 7 years. The prognosis is generally favorable with approximately 80% of children outgrowing their seizures by adolescence.

A 3-year-old girl presents because she is not using her left arm. Her father was playfully swinging her around by her forearms earlier in the day. What is the most likely diagnosis?

Radial head subluxation (**nursemaid's elbow, is the most common elbow injury in children. It typically occurs in children ages one to four years and is caused by traction of a pronated forearm while the elbow is extended. This occurs when a parent is swinging a child around while holding onto their hands or forearms, or when pulling a child's arm to prevent the child from falling. Patients with a radial head subluxation present with little distress and hold their arm close to their body with the elbow either fully extended or slightly flexed with a pronated forearm. Edema and ecchymosis at the site are uncommon. Supination of the forearm elicits increased pain. Diagnosis is made clinically, but radiographs may be useful to rule out fracture. Treatment includes reduction of the radial head by supinating and flexing the forearm.)

A 14-year-old boy presents to the clinic for a well child check. He has been growing well and has no medical complaints. On exam, he is found to have a III/VI systolic crescendo-decrescendo murmur heard best over the left sternal border. The murmur increases when moving from a squatting position to a standing position, and increases with Valsalva maneuver. The point of maximal impulse is displaced laterally. Which of the following is the next best step in management?

cease physical activity until further evaluation performed (**hypertrophic cardiamyopathy) Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disease with variable expression that presents with a classic murmur. The murmur is usually delayed in onset, 3-4/6 grade, and has a crescendo-decrescendo pattern loudest over the left lower sternal border. The murmur increases when venous return is decreased. Therefore, the murmur increases when moving from a sitting to standing position. Classic ECG findings include left ventricular hypertrophy, prominent septal Q waves, and abnormal repolarization or strain (e.g. negative T waves in V6). An echocardiogram is diagnostic and will show septal and ventricular wall hypertrophy. The most feared complication is sudden cardiac death from a dysrhythmia. Treatment options include limiting tachycardia to preserve ventricular filling; therefore, options include avoiding physical activity and prescribing beta-blockers. Cardiac defibrillators and transplant are more definitive treatment options

A 14-year old girl is accompanied by her parents for amenorrhea. She never had menses. She denies sexual activity and does not take any medications. She is a straight A student in school and plays basketball. On physical examination, her height is at the 90th percentile, weight at the 50th percentile, breasts at Tanner II, no axillary hair and no pubic hair. The rest of her examination is normal. Which of the following is the most likely diagnosis?

complete androgen insensitivity syndomre (*he girl in the vignette most likely has complete androgen insensitivity syndrome (AIS) (formerly known as testicular femininization). Complete AIS is an extreme form of failure of virilization wherein genetic males appear female at birth and are invariably reared accordingly. The external genitalia are female. The vagina ends blindly in a pouch, and the uterus is absent. This is due to the normal production and effect of antimullerian hormone by the testes. The testes are usually intra-abdominal although some may descend into the inguinal canal. At puberty, the diagnosis is suspected by the normal development of breasts, but menstruation does not occur and sexual hair is absent. Adult heights are commensurate with those of normal males. Management of patients with complete AIS involves removal of testes whose sexual orientation is unambiguously female. This can be done through laparoscopic removal of Y chromosome-bearing gonads.)

A 2-year-old previously healthy female presents to the ED with complaints of 3 days of low-grade fever and congestion followed by noisy breathing and cough. Upon examination, you note a frequent barking cough, audible stridor at rest, and retractions. The child does not appear to be in any distress. what s the most appropriate next step in management?

moderate croup: oral steroids and racemic epinephrine nebulizer and observed in ED for 3 hours and discharged if symptoms abate.

A 9-year-old boy presents with 3 months of progressive spine stiffness. He also complains of hip, ankle, wrist and digit pain. There is no rash present. Physical and laboratory examination supports a diagnosis of juvenile rheumatoid arthritis. Which of the following is this patient most likely to be prescribed?

methotrexate he most common childhood arthritis is juvenile idiopathic arthritis (JIA). Onset must be less than 16 years of age and symptoms persist > 6 weeks. Other causes of childhood arthritis include vasculitis, rheumatic fever and septic arthritis. There are three main subtypes. Systemic JIA, also known as Still's disease, occurs in 1-6 year old children, and is characterized by intermittent spiking fever and rash. Rheumatoid factor (RF) is negative in about 98% of these cases. Pauciarticular JIA is an oligoarthritis that occurs in girls earlier than boys, and is characterized by few systemic findings except for serious ophthalmologic complications of uveitis and iridocyclitis. Again, RF is negative in more than 98% of these patients, however, HLA-B27 is commonly positive. The most common subtype, responsible for 90-95% of all JIA, is termed Polyarticular. It is characterized by an onset > 8 years of age, and is marked by insidious edema and stiffness, especially in the spine and hip. This type may lead to growth retardation due to early epiphyseal plate closure. Systemic features are rare, however, when this type occurs in an unremitting pattern, it carries the worst prognosis of all the subtypes. RF is positive in only 5-10% of polyarticular JIA, and is present most commonly in females over the age of 10 years. Overall, 70% of children with JIA improve without serious disability, but 10% succumb to devastating functional impairments. A multidisciplinary approach is necessary for maximum treatment results, and includes physiatry, rheumatology, ophthalmology, physical and occupational therapy and behavior health therapy, as well as NSAIDs, salicylates, methotrexate, sulfasalazine, etanercept, adalimumab, infliximab, intraarticular steroids and possibly orthopedic surgery.

A five-year-old boy is brought to the ED by his mother for leg pain. He was playing with his sister when he fell and cried. He cannot move his right lower leg. The mother had a hard time explaining how the boy sustained the injury. She said he had several fractures in the past. His father also has history of multiple fractures and hearing loss. On examination, the boy's height is at the 5th percentile, he has normal motor and sensory examination of the right foot and ankle with strong pulses, slight swelling of the right leg with tenderness at the tibia. You suspect a right tibial fracture. Which of the following is the most likely diagnosis?

osteogenesis imperfecta (**The boy has history of multiple fractures with a family history of multiple fractures and hearing loss. These findings are suspicious for osteogenesis imperfecta (OI). OI or "brittle bone disease" is an inherited connective tissue disorder. Most patients have an autosomal dominant mutation in the gene that affects the structure of one of the two alpha chains of type I collagen. The severity of the clinical presentation depends upon the effect of the mutation. The clinical manifestations vary within families. Clinical manifestations of OI include excess or atypical fractures, short stature, scoliosis, basilar skull deformities, blue sclerae, hearing loss, opalescent teeth that wear quickly, increased laxity of the ligaments and skin, wormian bones, and easy bruisability. There are reports of elevated alkaline phosphatase and hypercalciuria. The clinical diagnosis is based on the signs and symptoms as described, which is straightforward in individuals with bone fragility and a positive family history or several extraskeletal manifestations.)

A 14-year-old girl is in your clinic with her mother because of leg pain. She fell from her bike last month and hit her left leg. Since then, she has complained of pain on her left leg that waxes and wanes. On physical examination, you could palpate a soft tissue mass that is tender. Laboratory findings show elevated alkaline phosphatase and elevated lactate dehydrogenase. Radiograph reveals destruction of the normal trabecular bone pattern and a soft tissue mass that is ossified in a radial or sunburst pattern. Which of the following is the most likely diagnosis?

osteosarcoma

An obese, 15-year-old boy presents with a history of a limp for 2 months with some vague non-specific hip pain. Physical examination of the affected hip reveals a restriction of internal rotation, abduction, and flexion. On exam you note that when examining the affected hip the patient refuses to allow any range of motion of the hip. The extremity is shortened, abducted, and externally rotated. There is no history of trauma. what is the most likely diagnosis?

slipped capital femoral epiphysis (SCFE) (**A fracture in the physis (growth plate) of the femoral head can lead to slippage of the overlying epiphysis, leading to the condition slipped capital femoral epiphysis (SCFE). The classic patient presenting with SCFE is an obese boy between the ages of 11 and 16 years. Girls present earlier, usually between 10 and 14 years of age. Patients with chronic and stable SCFEs tend to present after weeks to months of symptoms. Patients usually limp to some degree and have an externally rotated lower extremity. Physical examination of the affected hip reveals a restriction of internal rotation, abduction, and flexion. Commonly, the examiner notes that as the affected hip is flexed, the thigh tends to rotate into progressively more external rotation. Chronic SCFE is the most common form of presentation. Typically, an adolescent presents with a few-month history of vague groin, thigh, or knee pain and a limp. Radiographs show a variable amount of posterior migration of the femoral epiphysis and remodeling of the femoral neck in the same direction; the upper end of the femur develops a bending of the neck.)

A 7-month-old girl presents to the emergency department with difficulty breathing. Her parents report two days of cough and congestion with one day of increased work of breathing. On exam, her temperature is 37.4°C, heart rate 140, blood pressure 94/65, respiratory rate 65, and oxygen saturation 90%. She has moderate suprasternal and subcostal retractions, mild intercostal retractions and slight head bobbing. On auscultation, she has diffuse polyphonic wheezing with crackles. what is the next best step?

suction nares (** bronchiolitis: Supportive care remains the first-line therapy while in the hospital, which includes suctioning of the nares with saline drops.)

A 7-year-old boy with scrotal pain for the past 3 days presents to your office. Upon examination, there is a swollen left hemiscrotum with visible overlying erythema. There is a visible dark blue dot present in upper pole of the left testicle. What is the most likely diagnosis?

torsion of the appendix testis (**he appendix testis is a vestigium of the mullerian ductal system. Torsion of the appendix testis is the most common cause of testicular pain in boys 2-10-years-old. Torsion of the appendix testis is characterized by subacute pain with progressive inflammation of the testis and epididymis causing scrotal pain and erythema. During palpation, a 3-5 mm indurated mass may be felt in the upper pole. In some cases, the tissue that had undergone torsion is visible as a "blue dot" sign through the scrotal skin. Usually the inflammation resolves by 3-10 days and is treated with rest and NSAIDs.)

A 3-year-old boy presents with severe vomiting and diarrhea. The exam reveals sunken eyes, skin tenting and a capillary refill of 3 seconds. He weighs 13 kg. He was 15 kg at his last well visit. Using the Holliday-Segar method, what is his maintenance fluid rate per hour?

47.9ml/hr

A 9-year-old boy presents to the ED with bilateral knee pain, low-grade fever, nausea, vomiting, and diarrhea for the past 4 days. His vital signs are blood pressure of 116/80 mm Hg, heart rate of 98 beats per minute, respiratory rate of 14 breaths per minute, and a temperature of 38.1°C. On examination, you note the rash seen above. Urinalysis is positive for hematuria. Which of the following statements is the most accurate? A Despite plasma exchange, most patients progress to chronic renal impairment B Long-term prednisone therapy improves 5-year survival to greater than 50% C disease is self limiting. most cases resolve within 6-8 weeks. D without treatment, the disease carries a mortality rate of 80% at one year

C (self limiting) (**Henoch-Schönlein purpura (HSP). small children, follow URI HSP classically presents with fever, abdominal pain, arthritis, hematuria, and a pathognomonic round, palpable, symmetrical rash that appears on the dependent areas of the legs and buttocks. NSAIDs, dapsone, and prednisone have all been shown to relieve symptoms. The course of disease is typically self-limited. Most cases resolve within 6 to 8 weeks, with a recurrence rate of up to 33%.

A 12-year-old girl presents to the office with anal itching that seems to be worse at night. She has no issues with constipation or any other changes in her bowel habits. On physical exam you see some excoriations around the anus but no tear or palpable hemorrhoid. This first occurred a few days after returning home from a summer camp in northern Michigan, where she was in a cabin with 15 other girls for one month. what is most likely dx?

pinworms (**Diagnosis is made by the cellophane tape test and all members of the household should be treated. Pinworm infection is readily treated with a single 100-mg dose of mebendazole or a 400-mg dose of albendazole)

What is the most common system involved in children with active tuberculosis?

pulmonary

A 6-week-old boy presents with a 3-week history of progressive non-bilious vomiting. There is no history of recent fever, diarrhea or blood in his stool. The physical exam reveals minimal weight gain over the past two weeks. what is dx?

pyloric stenosis

o reduce the risk of secondary cases, chemoprophylaxis with oral rifampin is necessary for household contacts and anyone who has had direct exposure to an index case's oral secretions up to how many days before the index case's onset of illness?

7 days

Which of the following is most characteristic of a complex febrile seizure? A. convulsions are focal in nature B. convulsions lasting 12 minutes C. second seizure occurs with second febrile illness D. single seizure that occurs at a temp of 40 C.

A (*Complex febrile seizures are diagnosed when multiple seizures occur during the same febrile illness, seizures are prolonged (>15 minutes), or the seizures have a focal component. Simple febrile seizures are associated with generalized convulsions)

What is the cellophane tape test for pinworms?

A two- to three-inch piece of clear tape is applied serially to several perianal areas in the morning before washing. The tape is then applied to a glass slide.

In which of the following conditions is hypoxemia caused by a right-to-left shunt? A. Asthma B. Eisenmenger's syndrome. C. Patent foramen ovale D. Pulmonary embolism

B (**ncorrected left-to-right shunt, such as a ventricular septal defect, atrial septal defect, or patent ductus arteriosus, can eventually become a right-to-left shunt, a phenomenon known as Eisenmenger's syndrome. This occurs when increased pulmonary blood flow from a left-to-right shunt leads to pulmonary hypertension and compensatory right ventricular hypertrophy, and, over time, right ventricular pressures surpass left ventricular pressures, resulting in a change in direction of the shunt.)

Which of the following is most likely to present as a ductal-dependent cardiac lesion? A. ASD B. Coarctation of the aorta C. Isolated ventricular septal defect D. Mitral valve prolapse

B coartation of the aorta (**Patients with coarctation of the aorta may present with circulatory failure and shock upon closure of a patent ductus arteriosus (PDA). In many cases, the coarctation of the aorta occurs juxtaductal (adjacent to the PDA). The PDA may serve to widen the juxtaductal area of the aorta so that blood may flow forward from the left ventricle. However, in other cases, the PDA serves as a conduit for right-to-left shunted blood from the right ventricle. In the latter case, infants classically present with differential cyanosis due to well-oxygenated blood reaching the upper body (pink) from the ascending aorta, and deoxygenated blood reaching the lower body (blue) via the PDA and descending aorta. This is because the PDA often inserts distal to the origin of the left subclavian artery from the aorta. When the ductus arteriosus closes, this can lead to circulatory failure and shock.)

Ocular erythromycin prophylaxis for newborns provides prophylaxis for which of the following? A. Chlamydia trachomatis B. Streptococcus agalactiae C. Neisseria gonorrhoeae D. Treponema pallidum

C (** Ocular erythromycin is routinely administered to neonates to prevent the transmission of Neisseria gonorrhoeae from mother to child. Ocular prophylaxis is safe, effective, and inexpensive. Erythromycin ointment causes significantly less chemical conjunctivitis than silver nitrate, which was the previous standard of care for ocular prophylaxis. However, silver nitrate is more effective prophylaxis for patients with penicillinase-producing N.gonorrhoeae, and thus it is still indicated in areas where resistant N.gonorrhoeae is prevalent. Topical erythromycin is not effective in preventing mother-to-child transmission of Chlamydia trachomatis (A). However, oral erythromycin is the drug of choice of neonatal chlamydial conjunctivitis.

Which of the following statements is correct regarding Osgood-Schlatter disease? A. disorder requires surgical intervention B. occurs commonly in women over the age 30 C. pain occurs over the tibial tuberosity D. requires MRI for confirmation of dx

C (**Osgood-Schlatter disease manifests as pain over the tibial tubercle in a growing child. The patellar tendon inserts into the tibia tubercle, which is an extension of the proximal tibial epiphysis. Osgood-Schlatter disease is likely a traction apophysitis of the tibial tubercle growth plate and the adjacent patellar tendon. It occurs during late childhood or adolescence, especially in athletes, and is likely due to repetitive tensile microtrauma. There is often increased prominence of the tibia tubercle that is also firm. Radiographs can be normal or may show small spicules of heterotopic ossification anterior to the tibial tuberosity. This disorder is self-limited in most patients and resolves with skeletal maturity.)

A 4-week-old boy presents with a 2-week history of increasing dyspnea, cough, and poor feeding. On examination you note conjunctivitis, and a chest examination reveals tachypnea and rales. A chest X-ray shows hyperinflation and diffuse interstitial infiltrates. Which of the following is the most likely etiologic agent?

Chlamydia trachomatis

What medication should be used in the treatment of RMSF in pregnant patients or those with allergies to tetracyclines?

Chloramphenicol.

A 7-year-old boy presents with five days of abdominal pain, arthralgias, and a rash of the lower extremities. Mild diffuse abdominal tenderness is noted on examination. The left knee and right ankle are swollen and tender without warmth or erythema. The rash consists of purple, non-blanching macules and papules of both legs and thighs. Which of the following is indicated? A. abdominal US - intussusception B. ANA - rheum C. CBC - thrombocytopenia D. U/A - glomerulonephritis

D (**Thus, this patient requires a urinalysis to evaluate for glomerulonephritis, specifically to evaluate for blood, casts, and protein. Renal manifestations of HSP vary widely. While 20-30% of children develop gross hematuria, others develop a range of manifestations from asymptomatic hematuria or non-nephrotic range proteinuria to acute renal insufficiency. The child must be screened for development of renal disease over at least six months following presentation, as renal manifestations of HSP can continue to develop after other signs and symptoms have resolved. 91% of children who develop renal disease will present within six weeks and 97% by six months. If urinalysis is normal six months after presentation, there is no further risk of permanent renal damage.)

A six-year-old girl is brought by her mother to the clinic due to fever and sore throat. The girl has had a fever for five days with a maximum temperature of 38.5°C that is minimally responsive to antipyretics. She is irritable with decreased appetite. On examination, there is bilateral bulbar injection, erythema of oral mucosa, enlarged anterior cervical nodes, and macular rash on trunk and extremities. what is the most likely diagnosis?

Kawasaki disease (**KD is also known as mucocutaneous lymph node syndrome and is one of the most common vasculitides in children. There is widespread inflammation of medium-sized muscular arteries. Diagnosis of KD requires the presence of fever that lasts ≥ 5 days with four of the five physical findings without an alternative explanation. These findings include bilateral bulbar conjunctival injection, oral mucous membrane changes (injected or fissures lips, injected pharynx, or strawberry tongue), peripheral extremity changes (erythema of palms or soles, edema of hands or feet, or periungal desquamation), polymorphous rash, and cervical lymphadenopathy. Management of KD involves treatment with intravenous immune globulin (IVIG) within the first 10 days of illness that reduces the prevalence of coronary aneurysms.)

What criteria on ultrasound are consistent with pyloric stenosis?

Pyloric wall greater than 4 mm wide or 14 mm long.

A 4-week-old boy presents with a 2-week history of increasing dyspnea, cough, and poor feeding. On examination you note conjunctivitis, and a chest examination reveals tachypnea and rales. A chest X-ray shows hyperinflation and diffuse interstitial infiltrates. Which of the following is the most likely etiologic agent? A Chlamydia trachomatis B Parainfluenza virus C Respiratory syncytial virus D Staphylococcus species

a (**Staphylococcal pneumonia (D) has an abrupt onset. The infant appears very ill and has a fever. Signs of tachypnea, dyspnea, and localized or diffuse bronchopneumonia or lobar disease may be present with prominent leukocytosis on blood work. Respiratory syncytial infections (C) usually cause lower respiratory tract infections, such as bronchiolitis. These children have cough, fever, rhinorrhea, wheezing, labored respirations and occasionally hypoxia. Chlamydial infections may be differentiated from respiratory syncytial infections by a history of conjunctivitis and a subacute onset. Patients with parainfluenza virus (B) typically present with a history of coryza and low-grade fever; they then develop the classic barking cough associated with croup.)

11-month-old infant reports to ED for inconsolable crying. You note the infant lying in the stretcher crying with his knees drawn to his chest. You perform a physical exam and leave the room to order blood work. When you return to the examination room, you note the infant now appears lethargic. An abdominal radiograph is obtained and interpreted by the radiologist as nonspecific. what dx test should be performed next?

abdominal US (**In patients with suspected intussusception, ultrasound is a quick, noninvasive diagnostic modality commonly used for the diagnosis of intussusception. One study reported that the overall sensitivity and specificity of ultrasonography for detecting ileocolic intussusception was 97.9% and 97.8%, respectively. The authors concluded that ultrasonography should be used as a first-line examination for the assessment of possible pediatric intussusception. Ultrasonography eliminates the risk of exposure to ionizing radiation and can help to depict lead points and residual intussusceptions. It also helps to rule out other possible causes of abdominal pain. On the transverse ultrasound scan, the intussusception appears as a multilayered or wrapped complex mass; longitudinally, it appears as a tube within a tube.)

A previously healthy 17-year-old boy is brought to the ED by ambulance. He became very ill over the past few hours. His vital signs are T 39.4ºC, HR 142, BP 90/52, RR 20, and a pulse oximetry of 94% on room air. On exam, he has a stiff neck and the rash seen above on his leg. You establish an intravenous line, draw a blood culture, order a complete blood count and electrolyte assessment, and administer a fluid bolus. what do you do next?

administer IV ceftriaxone and vancomycin (**his patient is presenting with severe meningococcal septicemia caused by the aerobic gram-negative diplococcus N. meningitidis,. delay Lumbar puncture until after antibiotics administered)

A mother brings her 7-year-old boy into the clinic. She reports that the child has been complaining of fatigue, headache and myalgias since he returned home from a camping trip with his father. His mother points out an annular rash with central clearing on the child's torso. Which of the following is the most appropriate treatment for this patient's condition?

amoxicillin

You suspect a cardiac structural defect in a 6-month-old infant with peripheral edema and hypertension. Skin color is normal. A murmur is not appreciated. However, the blood pressure is markedly higher in the arms than legs. what is the most likely dx?

aortic coarctation (**oarctation of the aorta is characterized by narrowing of the aorta anywhere along its length but most commonly around the left subclavian artery takeoff. This acyanotic lesion presents with congestive heart failure, cardiomegaly, hypertension and shock. The classic exam finding is blood pressure higher in the arms than legs, and pulses bounding in the arms and decreased in the legs. Rib notching (inferior aspect of the rib) is the classic radiographic finding in patients with coarctation of the aorta. This occurs as a result of dilatation of intercostal arteries. Surgical correction is usually required, and is most commonly performed between 2 and 4 years of age.)

A 4-month-old infant is brought to clinic with concerns of rash. Over the past week, his mother noted a red rash over both of his cheeks. The rash has neither spread nor remitted. He has otherwise been healthy. On examination, he exhibits erythematous, scaling, excoriated plaques over both cheeks. What is the most likely diagnosis?

atopic dermatitis (**Atopic dermatitis is an inflammatory skin condition that affects children and adults of all ages. It is a result of an overactive response to a variety of stimuli, including food allergens, inhaled allergens, irritant cosmetics, weather and humidity changes, pollution, and stress. Atopic dermatitis commonly causes diffuse xerosis, as well as eczematous plaques, papules, and crusting. In infants, plaques are most commonly distributed over the cheeks, as well as the extensor surfaces of the extremities. In older children, the face is less often involved, and the flexor surfaces of the extremities, such as the antecubital fossa, are frequently affected)

A 14-year-old girl presents with right thigh pain that has been going on for the last month. She recalls being kicked in the leg during soccer practice before her symptoms started. She was last seen in the ED two weeks ago and was diagnosed with a muscle contusion. On exam there is a mass palpable over the anterior distal thigh. X-ray of the femur shows a distal femoral diaphyseal lesion with cortical destruction and periosteal reaction with high suspicion for osteosarcoma. Which of the following is true regarding this disease? A. Blunt trauma is associated with the pathogenesis of osteosarcoma B. Ionizing radiation for a childhood cancer is a risk factor for osteosarcoma C. Osteosarcoma most often involves the axial skeleton followed by the long bones D. Pathologic fracture is a common presenting sign

b (**Patients diagnosed with osteosarcoma will often describe a history of mild blunt trauma (A), however there is no evidence to support a causal relationship between blunt trauma and osteosarcoma. Osteosarcoma is more common in the long bones (C) with the most frequent sites in descending order being femur, tibia, and humerus. Pathologic fracture (D) is possible, though it is a rare presenting sign.)

A 12-year-old boy presents to the emergency department with recurrent headaches. The headaches have been present for the past four weeks and are increasing in intensity. They are worse in the morning and when lying flat, and are associated with vomiting but no nausea. For the past few days, he has complained of blurry vision. His initial exam is notable for altered mental status, extensor posturing, and papilledema. what are the most likely vital sign abnormalities?

bradycardia, hypertension, and irregular respirations (** patient is experiencing increased ICP. may result from many etiologies including swelling, masses, or increases in blood or CSF volumes. Increased ICP leads to physiologic compensatory mechanisms, but uncompensated elevated ICP may result in brain ischemia and ultimately in cerebral herniation. Vital sign and physical exam findings associated with cerebral herniation are systemic hypertension with widened pulse pressure, bradycardia, irregular respirations, pupillary dilation (often unilateral), and extensor posturing. Therefore, a heart rate of 40, BP of 155/65, and irregular respirations is most consistent with elevated intracranial pressure. Management of increased ICP and impending cerebral herniation includes maintaining euvolemia and euglycemia, head of the bed elevation, hyperventilation, and either mannitol or hypertonic saline (3%) infusion. These patients should have a secure airway placed since they are at risk for apnea. A CT scan should be obtained to evaluate for intracranial masses. Complications include seizures, SIADH and salt-wasting, hyperglycemia, and motor and cognitive delays.)

A 17-month-old boy presents with bilious vomiting, fever, and abdominal distention for the past three days. The mother states she noticed blood in the last diaper she changed. What is the most likely diagnosis?

intussusception (**The presence of bilious vomiting should always raise concern for intestinal obstruction such as intussusception. Intussusception is commonly caused by a pathological lead point. This is a lesion or variation in the intestine that is trapped by peristalsis and dragged into a distal segment of intestine. This causes bowel obstruction and ischemia. The most common location is when the terminal ileum telescopes into the right colon. It is usually diagnosed via ultrasound, which shows a "coiled spring" or "target lesion" representing layers of intestines within the intestine. Surgery is indicated in patients who are acutely ill or have evidence of perforation. Otherwise, patients are treated with non-operative reduction using hydrostatic or pneumatic pressure by enema.)

A four-year-old boy presents to the emergency department for inability to walk. He has had two days of leg pain and has been irritable for the past day. The morning of presentation, he refused to get out of bed or bear weight. On his initial examination, he has 1/5 strength in his lower extremities, and 4/5 strength in his upper extremities. Patellar reflexes cannot be elicited. Which of the following is the most likely CSF finding? A. WBC 120, Glucose 20, Protein 80 B. WBC 120, Glucose 65, Protein 80 C. WBC 2, Glucose 65, Protein 135 D. WBC 2, Glucose 65, Protein 40

c (**Guillain-Barré syndrome postinfectious polyneuropathy that can affect patients of all ages. It typically follows a viral illness (e.g., Epstein Barr virus and cytomegalovirus) but has also been associated with some immunizations. Typically, the weakness begins in the lower extremities, then ascends along the trunk. Bulbar muscles may be involved, and respiratory failure can occur. Young children may present with refusal to bear weight, irritability, and flaccid tetraplegia. Tendon reflexes may be lost early or later in the course. Analysis of the CSF is helpful in making the diagnosis of Guillain-Barré. CSF studies will show an elevated protein level, typically twice the upper limit of normal. The white blood cell count in the CSF is normal. This dissociation between high CSF protein and normal cell counts (albuminocytologic dissociation) is diagnostic for Guillain-Barré syndrome. In addition, the CSF glucose level falls within the normal range. Bacterial and viral CSF cultures will be negative. Imaging studies may support the diagnosis. MRI findings might include contrast enhancement of the intrathecal nerve roots and the cauda equina on postgadolinium T1-weighted images.

A 2-year-old boy is being evaluated for dysphagia and difficulty breathing. His mother tells you his symptoms suddenly began about 3-hours ago. His immunizations are up to date. He appears restless, irritable, and is drooling. His temperature is 40.0°C (104°F). Physical examination shows suprasternal and subcostal retractions. Auscultation of the lungs reveals inspiratory stridor. Blood cultures are pending. what is the most appropriate treatment for this patient's condition?

ceftriaxone + vancomycin (** patient has acute epiglotitis: need to watch out for MRSA, strep even though HIB is most common cause. )

A family brings in their 3-month-old infant who was just adopted from Honduras. They are not aware of the infant's birth history and were told that the child was healthy and lived in an orphanage for the first three months of life. They are concerned that he has significant bruising over his back. On examination, a large blue patch is present over the sacrum. Similar patches are present over the bilateral shoulders. The remainder of the examination is benign. what is the most likely dx?

dermal melanosis aka mongolion spot (** most commonly found on sacrum and shoulders, most fade with time by grade school. no tx needed. )

A 3-year-old girl presents to the ED with 1 hour of a barking cough and inspiratory stridor at rest. On exam, she has mild retractions but is not hypoxic. Which intervention has been shown to reduce hospital length of stay in moderate to severe croup?

dexamethasone

An 11-year-old girl presents with a rash for the past 2 weeks. Her mother states that the rash began as a single red spot on the patient's upper back and then spread to the rest of her body. On physical exam, you note pink maculopapular oval patches on the patient's trunk. What treatment is indicated?

diphenhydramine aka benadryl (**pityriasis rosea. common in spring and fall seasons. herald patch . rash resolves in 3-8 weeks)

A four-year-old from Guatemala presents to the emergency room with a fever, drooling, and inspiratory stridor. Dad states that the child appeared well the day prior to presentation. The child is sitting with his neck extended. what is the most likely diagnosis?

epiglotitis (*Epiglottitis presents with rapid onset of respiratory distress, high fever, muffled voice, and drooling. Physical exam is significant for an anxious child with stridor. They are typically sitting in a tripod position, leaning forward with their neck extended. Epiglottitis is a clinical diagnosis; however, a lateral neck X-ray may aid in the diagnosis. The classic thumb print sign can be seen where the enlarged rounded epiglottis extends into the hypopharyngeal airway. Thickening of the aryepiglottic folds are also suggestive of epiglottitis. Patients should be observed closely for airway compromise. Some patients require advanced airway management, which should be performed in the operating room by an anesthesiologist. Parenteral antibiotics should be administered to cover Haemophilus influenzae B, Streptococcus pneumoniae, β-hemolytic Streptococci, and Staphylococcus aureus. Antibiotics can be narrowed based on culture and sensitivities. The rate of epiglottitis has decreased since the introduction of the HiB vaccine. However, this patient is from another country and may not have received the HiB vaccine.)

A 3-month-old presents with three days of cough, congestion, and increasing work of breathing. On exam, respiratory rate is 60 breaths per minute with moderate subcostal retractions. Air movement is good, but there are scattered rhonchi, crackles, and expiratory wheezes. Heart rate is 145 beats per minute with a regular rate and rhythm and no murmurs. Oxygen saturation is 89% on room air. Which of the following is the next step in management?

initiate supplemental oxygen by nasal cannula

An eight-year-old girl presents to your office with complaints of increased thirst, increased volume of urine and weight loss. Physical exam is normal except for the patient appearing slightly ill and with a weight loss of seven pounds since her last well child. what is the most appropriate therapy?

insulin (**Type 1 diabetes mellitus (DM) occurs when autoimmune destruction of the beta cells of the pancreas make the body unable to produce insulin. Onset of the condition occurs most commonly in children, but it can also develop in adults. Family history of type 1 DM is a risk factor for developing the disorder. The classic symptoms include polyuria, polydipsia, polyphagia, and weight loss. Onset can occur suddenly, and individuals often present with diabetic ketoacidosis as the initial presentation. Diagnosis can be confirmed with a random plasma glucose concentration of 200 mg/dL or higher in a patient with symptoms of hyperglycemia, a fasting plasma glucose concentration of 126 mg/dL or higher on more than one occasion, a positive oral glucose tolerance test or a glycated hemoglobin (A1C) of 6.5 percent or greater. Treatment is with exogenous insulin since the body is unable to produce insulin on its own.)

A 9-year-old boy presents with penile pain. On genitourinary exam the distal prepuce cannot be reduced over the glans penis and there are thin adhesions to the glans, which is swollen. What is the next best step in management?

manual reduction after topical lidocaine (** is a medical emergency and can cause venous engorgement and glans edema which can lead to ischemia. It most often occurs when the foreskin is forcibly retracted to clean the penis and the foreskin is not returned to its natural position. Boys younger than age 4 are particularly susceptible to paraphimosis because their foreskin is not fully mobile.)

A 4-month-old female presents with a diaper rash following four days of loose stools. The rash consists of erythematous, raised plaques and papules over the labia, inguinal folds, perineum and buttocks. What treatment is indicated?

nystatin ointment 2 to 3 times per day until rash resolved for 48 hours (**The infant has classic findings of candidal diaper dermatitis, including beefy red plaques and satellite lesions. In contrast to the rash of irritant diaper dermatitis, the inguinal folds are usually involved. Candidal diaper dermatitis results from fungal invasion of superficial microtears in the skin. Candidal diaper dermatitis is usually clinical apparent, but potassium hydroxide preparation of skin scrapings may be used to confirm a diagnosis in unclear cases.

A six-year-old girl presents with dark urine and pedal edema and is found to have an elevated blood pressure. She was treated for strep pharyngitis two weeks ago. What is the next best step in terms of what dx test to perform ?

obtain U/A (**The patient in this vignette likely has poststreptococcal glomerulonephritis (PSGN). In any patient with concern for renal disease, a urinalysis should be obtained. In patients with renal disease, urine dipstick results show large amounts of blood and protein. Microscopic analysis usually yields leukocytes and white blood cell casts. Red blood cells may appear dysmorphic and can be present with red blood cell casts. Red blood cell casts may or may not be related to PSGN but is pathognomonic for glomerular disease in general.)

A 16-year-old African American boy presents with a scalp rash. On examination, it is a 5 x 5 cm boggy and thickened area of the right parietal cap with an overlying scaly and crusty plaque and hair loss. The lesion appears yellowish-green under a Wood's lamp. What is the treatment of choice for this lesion?

oral griseofulvin (**A kerion is best treated with oral griseofulvin. A kerion is an abscess caused by a fungal infection most commonly on the scalp but may also present on the upper limbs and the face. It appears as a boggy, pus-filled lesion with significant inflammation. The overlying skin often has an eczematous, itchy rash as well as hair loss. The patient may also have nearby lymphadenopathy, fevers, and malaise. The fungal infections that can cause a kerion include Microsporum canis and the Trichophyton genus. Exam with a Wood's lamp reveals yellow-green fluorescence. Scrapings and hair samples can be sent for microscopy and fungal culture to confirm the diagnosis. A course of six to eight weeks of an oral anti-fungal agent such as griseofulvin, itraconazole, or terbinafine is recommended. Antibiotics may also be indicated if a bacterial infection is also present.)

A 15-year-old girl who follows a vegetarian diet is evaluated by her pediatrician for chronic fatigue. She is found to have a hemoglobin of 9.2 g/dL and ferritin of 15 ng/mL and is started on iron supplementation. Which of the following foods helps facilitate the absorption of iron?

orange juice (** Ascorbic acid, which is found in orange juice, doubles the absorption of non-heme iron. In infants over 4 months of age their iron-fortified cereals can be mixed with applesauce as this also contains ascorbic acid. Iron regulation primarily occurs in the gastrointestinal tract and is determined by the amount of iron stores, the rate of red blood cell production, the amount of iron present in the diet, the type of iron present in the diet and the presence of other foods that can either inhibit or promote iron absorption. Meat, fish and poultry contain heme iron which is 2 to 3 times better absorbed than the non-heme iron found in iron-fortified foods and plants.)

A 4-year-old girl presents complaining of left knee pain. The patient was started on antibiotics one week ago for a simple ear infection. She now has a widespread morbilliform rash, urticaria, several swollen joints, and temperature of 39.3°C. what is the most likely diagnosis?

serum sickness (**rash, joint pain, and fever a week after beginning antibiotics. Serum sickness is an immune-complex deposition disease (type III hypersensitivity) that occurs after exposure either to animal proteins or serum or to a variety of drugs. Serum sickness has distinctive cutaneous findings. Erythema first occurs on the sides of the fingers, toes, and hands before a more widespread morbilliform appears, sometimes with urticaria. Rash, fever, constitutional symptoms, and arthralgia are the most frequent clinical findings. Symptoms usually start 12 to 36 hours after ingestion if there has been previous immune system priming; absent this, onset may be delayed 7 to 21 days after antigen exposure. Treatment is supportive with antihistamines and antipyretics.)

A 3-year-old girl is brought in after her mother noticed a rash and bruising over her trunk and extremities. She also has intermittent epistaxis over the past few days. She had an upper respiratory illness 2 weeks ago but otherwise is well. Examination reveals a well-appearing child with scattered petechiae. Hemoglobin is 12 g/dL, WBC 8,000, INR 1.0, and platelets 8,000. what is most appropriate initial treatment?

steroids and IV immunoglobulin

A 16-year-old boy is brought to ED due to testicular pain. The pain started while he was running in physical education class. He denies any other symptoms. On exam you note that the scrotum is swollen, the left testis is tender and there is absence of cremasteric reflex. Which of the following is the most likely diagnosis?

testicular torsion (**The patient most likely has testicular pain due to testicular torsion. Testicular torsion is caused by inadequate fixation of the testis within the scrotum that results from a redundant tunica vaginalis, allowing excessive mobility of the testis. It requires prompt diagnosis and treatment to salvage the testis. Symptoms include pain that is sudden in onset, nausea and vomiting. It may be associated with exercise or minor genital trauma. On exam there is scrotal wall erythema, scrotal swelling, and absence of the cremasteric reflex. Evaluation is done with color Doppler ultrasonography to assess testicular blood flow and testicular morphologic features. Treatment is surgical exploration and detorsion)

A five-year-old child is brought to clinic with scalp itching. Adherent white flecks are noted around hair proximal to the scalp. What is the treatment of choice?

topical 1% permethrin (lice tx: others include: malathion, benzyl alcohol, spinosad, and ivermectin)

An 18-month-old male presents with a rash under his nose. The rash began as a papulovesicular eruption with surrounding erythema. The vesicles then ruptured and left behind a honey-crusted plaque. The rash has not spread, and the child has been otherwise well appearing. What is the most appropriate treatment?

topical mupirocin

A 3-day-old baby girl has a holosystolic murmur along the left lower sternal border. What is the most likely diagnosis?

ventricular septal defect (** Ventricular septal defects (VSD) present with a holosystolic murmur best heard at the left lower sternal border and is frequently accompanied by a thrill or displaced point of maximal impulse. A defect in the membranous (superior) portion of the ventricular septum is more common than in the muscular (inferior) portion. Auscultation is often sufficient to make the diagnosis of a VSD but confirmation can be obtained with echocardiography)

A 2-year-old boy presents with a one-day history of inspiratory and expiratory stridor. According to his mother, he has a fever of 38.3°C at home and a cough that sounds like a barking seal. On evaluation, the child is smiling and playful. He is sitting upright, and his voice is hoarse but not muffled. He is not drooling. His heart rate is 138 beats per minute, respiratory rate 28 breaths per minute, temperature 38.5 ºC rectally, and oxygen saturation of 98% on room air. what is the most likely dx?

viral croup