Peds - Week 2

All of your insides are switched (think liver on left, spleen on right) = situs inversus totalis = you'll be okay Just your heart is switched = situs solitus = major heart issues

Situs inversus - what's the problem?

Child abuse - forced oral sex

Multiple hard palate petechiae without clear cause - concern?

Coarctation of the aorta

"3 sign" on physical exam - suspected diagnosis?

Tetralogy of Fallot

"Boot shaped heart" on XR - suspected diagnosis?

- Classic osteoscarcoma (it's the most common) - Distal femur (40% ) - A "skip" lesion - MRI - Combo chemotherapy - if extreme, amputation

14 year old male patient has an unremarkable PMH, but has a swollen right knee for 8 weeks that has slowly been getting worse. XR shows "sunburst" bone pattern. What do you think he has? Where is this most common? If there was a second lesion higher on the bone, what would that be called? Does he need additional imaging?

- Ewing Sarcoma - bone cancer (second most common) - Yes - Aggressive malignancy - Multidrug chemotherapy

18 year old patient has an unremarkable PMH, but has had left leg pain and swelling for 3 months. XR reveal an "onion skin" deformity. He does not feeling feverish the last 3 weeks. What do you think he has? Is it malignant? What are the risks? How do you treat it?

- Encopresis - DSM 5 - psych thing! - child >4yo, repeated passage of stool, for at least 3 mos - Treat constipation - behavioral (sit on toilet after meals), fiber, laxatives, mineral oil

6 y/o boy whose parents report a hx of large infrequent stools who presents with small volume liquid stools soiled into underwear What is this called? What do you use to diagnose? How do you treat?

- fissure in ano - YES, 80% of children get them and they are most common in this population - inspection - palpation can cause severe pain - Sitz baths, adequate fiber, topical treatments (nitroglycerin or diltiazem.... not sure if these are okay for a 10 month old), or Botox injections (ooooh!!) - Change diapers frequently, keep anal area dry, avoid constipation, increase fluid intake

A 10 month old is brought to your clinic by his mother. She is very concerned because he is constantly crying and she saw blood in his stool. Upon inspection, you see rocket shaped perianal ulcers posterior midline. What is going on? Are these common in babies? How do you test? How do you treat? How do you prevent?

- hydrocephalus - Fluid (CSF) build up in the brain - Infection, tumors, congenital - Provide outlet from CSF from intracranial compartment (shunting)

A 12 week old female infant presents to the emergency department with progressive vomiting, lethargy, and difficulty feeding over the past two days. Her mother reports that the infant has been increasingly irritable in the last week, and does not appear to be herself. She has been less interactive, and her cry has become more high-pitched and weak. She has not been breastfeeding well. Additionally, her mother is concerned because she thinks her infant's head has grown, and the "soft spot" on her head appears fuller. What do you think the diagnosis is? What does that mean? What can cause that? How do you treat?

- Slipped capital femoral epiphysis (SCFE) - The pain from the hip frequently radiates to the knee - Klein lines - If he can bear weight, stable - Surgery surgery surgery - not emergent, but not next month - Avascular necrosis

A 12 year old overweight male presents with a *painful* limp and says his knee hurts. He denies falling or any recent trauma. PE reveals decreased internal rotation of the hip. His *hip* XR is attached. What do you think is going on? Why did you get a hip x-ray if he had knee pain? What are those lines called? Is this case stable or unstable? How do you treat? What if you don't do that?

- Atrial septal defect - EKG - RBBB and right axis deviation - Echo - Surgery or catherization if symptomatic - if 1-3 yo, closure can still be spontaneous

A 14 year-old boy whose chief complaint is that he tires easily, is sent by his pediatrician to a cardiac referral for evaluation. The cardiologist found the patient's general appearance to be unremarkable. Listening to the boy's heart, he heard a wide split second heart sound and a pulmonary flow murmur. What do you think is going on? What is your next diagnostic test? What will this show? What do you do after that? How do you treat?

- neck stiffness - meningitis - lumbar puncture (leukocytosis, protein, glucose) - Empiric broad spectrum antibiotics - Hearing loss

A 14-year old male complained to his parents of feeling quite ill with headache, dizziness, nausea, and feeling very weak. After a rise in in his body temperature, an increase in the severity of his headache, and the development of a rash, he came in to see you. The patient had a temperature of 103.5 and an increased heart rate. What symptom do you need to ask this patient about? What are you concerned the diagnosis is? What is your diagnostic work up? How do you treat? What can be a complication?

- Coarctation of the aorta - Narrowing of proximal descending aortic arch - EKG (usually reveals left ventricular hypertrophy), CXR, and echo - First stabilize with prostaglandin, then surgical repair

A 15 year old male patient presents to the clinic with chest pain when he is playing soccer. The vitals taken by the MA reveal a blood pressure of 150/90 on RUE. Because you are an awesome and savvy PA, you check his blood pressure on his left leg, which is 120/70. You listen to his heart and hear a murmur in the left axilla. What do you suspect is going on? What is that? What is a normal UE vs LE BP change? What diagnostic work up will you do? How do you treat?

- depression - DSM - 5 or more of the following symptoms: depressed mood (irritable), changes in weight/appetite, anhedonia (can't feel pleasure), insomia, psychomotor agitation, fatigue, feeling worthless, diminished concentration, recurrent thoughts of suicide/death + distress + no substance abuse relation + no other mental disorder + no mania + present for two weeks - Refer - SSRIs - 90% get better by 2 years, but 60-70% recurrence in adulthood

A 16-year-old adolescent girl is brought by her mother to your office. The patient reports being fatigued at times and having issues with her self esteem. She denies having suicidal thoughts, or appetite problems. Her fatigue started at least a year ago. She has also noticed difficulty concentrating at school and doesn't finish her homework because she naps after school. Her mother adds that "she has become very irritable and cranky over the past year. I don't know what's gotten into her." What do you think is going on? How do you diagnose? How do you treat? Prognosis?

- mumps - paramyxocirus - supportive - fluids, analgesics and, of course, scrotal support - nerve deafness, low sperm count

A 16-year-old previously well girl presented with a fever for two or three days and with a left-sided facial swelling that had arisen within the previous 24 hours. Before it started she had a headache and aches. She denied any dental problems. On examination, she had an obvious large tender swelling of the left side of her face. She was generally unwell. What do you think this is? What causes it? How do you treat? How do you avoid? What are complications?

- cerebral palsy - chronic, static impairment of the muscle tone, strength, coordination or movements - Typically originated from some type of cerebral insult or injury before birth/prenatal period - Nonprogressive - Clinical presentation + brain imaging - Speech, physical and occupational therapy - botox injections??

A 2-year-old boy, born after a normal pregnancy and delivery, presents with an asymmetric gait. Examination reveals mild spasticity of the left upper and lower extremity, hyperactive left knee and ankle deep tendon reflexes, and decreased dorsiflexion of the left ankle compared with the right. When walking, the patient walks on his left toes, and his left arm is held mildly flexed at the elbow with the palm facing the floor (pronated forearm). The left calf is smaller in girth than the right. What do you think is going on? What is that? How does it happen? Does it get worse? How do you diagnose? What types of therapy are indicated?

- Constipation - Clinical history and physical (2+ symptoms) - Stool softeners and fiber - stooling schedule before school

A 4 year old girl is brought in by her father. He tells you she is concerned because she has only had one or two bowel movements per week and when she does it is "impressive" it's so big. He also mentioned she has been sitting in a funny squatting position when they go to the park. What is likely going on? How do you diagnose? How do you treat?

- *Trauma*, depression/anxiety, or learning disability - History - family environment, early childhood, depression, etc. Send home with assessments for parent and teacher. (the DSM criteria is a mile long... but includes inattention and/or hyperactivity/impulsivity before age 12, in multiple settings, interfering with life, and no other possible psych cause) - Red food dye.... JK JK, we have no idea, possibly genetics + enviro - Parent education, behavioral therapist, medications (start with stimulants - MPH or amphetamine aka Ritalin) - If suspected comorbidities/complicated unclear diagnosis

A 5 year‐old boy is brought in by his mother, she complains he is "bouncing off the walls." At home he "can't sit still" is "constantly fidgeting." In preschool, his teachers sometimes have him run laps around the classroom when the other kids are doing focused activities. She is worried he won't be ready to start kindergarten in the fall. The only way she can get him to sit still is to put him in front of a video game, which he will focus on for "hours at a time." However when she tells him it is time to stop he has terrible tantrums. He is also her naughtiest child: constantly doing things "he knows he's not allowed to do." She is at her wits' end and wants to know if this is just a normal boy with a lot of energy or if he has something wrong with him like ADHD or bipolar disorder. What should be on your differential for ADHD?How do you diagnose ADHD? What causes it? How do you treat? When do you refer?

- Enuresis - UTIs, constipation, anatomical variation - Behavioral changes (drink less water at night), alarm systems, if not effective, desmopressin acetate

A 7 year old boy is brought in by his mother because he wets his bed 2-3 times each week. He has never achieved complete nighttime dryness, despite being toilet trained at 3 yo. There is no history of daytime incontinence, frequency or urgency. He does not drink fluid during the day, most of his water intake is in the evening. Otherwise, he is healthy. Of note, mom has a history of bed wetting until 6 yo. What is this called? What do you need to rule out? How do you treat?

- CBC, lipase, ESR, CMP, celiac screen, ultrasound - Acknowledge pain is real - perform thorough history and PE (including DRE) - Try diet changes, acid suppression, GI consult!

A 7 year old boy is brought in by his mother because of abdominal pain. He is otherwise healthy, but has been missing school because of his pain. It never wakes him up at night and he does not have weight loss, fever, diarrhea or vomiting. What are some of the first diagnostic tests you will run? If they are normal, what is important to do? How do you treat?

Congenital hip dysplasia

Allis sign - suspected diagnosis?

- Intussusception - Invagination of one segment of intestine into another segment - Iliocecal valve - Ultrasound - Barium enema - surgery if severe

An 18 month old male presents to the emergency department with six hours of stomach pain. He awoke at 0400 crying. His mother carried him and he settled down after a few minutes and then fell back asleep. Over the next few hours, he woke up intermittently crying. His appetite has been poor since the onset of these symptoms. He is able to walk but prefers to be carried by his mom this morning. He is less playful than usual. He would sometimes *crouch down crying*. There is no vomiting or diarrhea. His last stool yesterday was normal. There is no fever, cough, or runny nose. There is no history of abdominal trauma. An abdominal series reveals a soft tissue density in the right lower quadrant. What do you think is causing his symptoms? What is that? What is the most common spot? What other imaging helps? How do you treat?

- Pertussis (bacterial) - Bordetella pertussis - The "mycin" antibiotics - DTaP, avoid respiratory droplets - Bronchopneumonia due to superinfection

At first I had sneezing, coryza (rhinnitis), and a cough at night. Now I have coughing fits with high, deep, respirations. My WBC is >15K. What do I have? What bug causes it? How do you treat it? How should I avoid it? What is the most common complication?

The septum primum and endocardial cushion don't fuse, blood goes from left to right and you have an *acyanotic* shunt

Atrial septal defects (primum) - what's the problem?

The septum secundum is creates too big of a hole in septum premum, blood flows from left to right.

Atrial septal defects (secundum) - what's the problem?

- Septum secundum - Thick (rigid) - Pressure on the right is greater than that on the left (at this stage). Because the septum 2 is on the right, the septum primum (green) is able to swing open, letting blood flow through the foramen ovale

Based on this diagram of the embryologic atria - what is the *blue* line? Is it thick or thin? Why is it important it is on the right?

- Septum primum - From top to bottom - Foramen primum is first - it isn't really a "hole" but rather the gap between the end of the developing septum and the black triangle (the endo cushion) - Foramen secundum - this really is a "hole" in the septum primum and eventually allows for foramen ovale

Based on this diagram of the embryologic atria - what is the *green* line? How does it develop? What is the first "hole" in it's development? and in what order do they develop? What is the second "hole"?

- Aorticopulmonary septum - It develops in a spiral fashion - Oxygen rich and oxygen poor blood

Based on this diagram of the embryologic ventricles - what is the blue/purple line? What is a special feature of this structure? What does it separate?

intestinal obstruction in newborns

Bilious vomiting, with or without abdominal distention, is an initial sign of ___________________.

Lymphoblasts (which produces T and B)

Cell type involved with ALL?

- anxiety disorders - separation anxiety, social anxiety, generalized anxiety - OCD, selective mutism, phobias, panic disorders, etc. - DSM 5 - Big list, but it's important to note adults need three associated symptoms, kids only need one (think fatigue, irritability, muscle tension, sleep disturbance, etc.) - Substance abuse, systemic issues like thyroid or blood sugar disorders - CBT and antidepressant (SSRIs)

Charlie, an 11 years old missed 18 days of school last month because he worries that something bad may happen to his mom while he is in school. Corinne's, a 14-year-old refuses to join an after-school clubs. When she did venture out with a cousin, it took her hours to do her makeup because she didn't think she looked quite right. Emily has difficulty falling asleep at night because her mind was "constantly racing" with thoughts and concerns about anything and everything. She can't even enjoy a relaxing activity, like reading or watching TV. What are these? What types are they? What are some other types? How do you diagnose? What should you screen more? How do you treat?

- Normocytic anemia - low platelets. Normal platelet volume = production problem. WBC are HIGH, specifically lymphocytes. - Acute lymphoblastic leukemia (ALL) - Age 50 (bimodal) - Methotrexate or steroids followed by intensifying chemotherapy

Child comes in with nosebleeds and fever on/off for 2 weeks and severe leg pain for one day. Labs show... What do his labs show? What do you think he has? What *other* age group is affected? How do you treat it?

Scoliosis

Cobb angle - whatcha thinkin?

Hodgkins (NHL is non-continuous)

Continuous lymph node spread - Hodgkins or Non-Hodgkins?

Acyanotic

Coronary artery disease - cyanotic or acyanotic?

Acyanotic

Defects in septation - cyanotic or acyanotic?

IVC --> RT atria --> foramen ovale --> left atria --> left ventricle --> aorta

Describe the flow of blood starting in the inferior vena cava in the embryologic heart

SVC --> RT atria --> RT ventricle --> pulmonary artery --> lungs (a little) --> ductus arteriosus --> distal aortic arch

Describe the flow of blood starting in the superior vena cava in the fetal heart

right thoracic, left lumbar scoliosis

Describe this finding (be specific)

Acyanotic

Diseases of the aorta - cyanotic or acyanotic?

- Patent ductus arteriosis - Echo or Ultrasound - Surgery - Hoarseness - RECURRENT LARYNGEAL

During a routine sports physical, the physician noted that a twelve-year-old boy, had a long continuous heart murmur at the second intercostal space near the left sternal border. A systolic thrill was also noted in the same region. When questioned, the patient's mother recalled that the child had periods of cyanosis and breathlessness as an infant, but that his previous pediatrician said that the murmur and the symptoms were nothing to be concerned about. The child mentioned that he tires easily during physical activity. CXR shows slight left ventricular hypertrophy. What do you think is going on? What is your next imaging step? How do you treat? What can be a complication? From what??

Failure of fusion of two sternal bars, causing the protrusion of the pericardium and heart.

Ectopia cordis - what's the problem?

- Retinoblastoma - Kinda, retinoblastoma is the most common intraocular cancer of childhood and affects approximately 300 children in the United States each year - Make sure that kid gets referred to an othalmologist - Yes, 90% are diagnosed before age 5 and have excellent prognosis

Flipping through pictures on Facebook, you notice a friend of a friend of a friend's daughter has a strange red eye in a picture. What is this a sign of? Is this common? What do you do? Is prognosis good?

- Pharyngitis - viral - No, unless we think it is strep throat - Sudden onset sore throat, fever, no cough, red uvula - To make sure it isn't strep - which can cause scarlet fever and PSGN - Confirm with culture

I am 5 and I my throat hurts. I also have a low grade fever. What is likely going on? Don't I get antibiotics?? What would make you think it was that? Why do you need to test? What if it's negative?

- Hodgkin - Contiguous lymph spread - biopsy lymph node to be sure - Chemotherapy/radiation

I am a 17 year old with painless, swollen lymph nodes that seems to be spreading out from my neck out to my collar bone. I have fever, night sweats, I've lost 15 lbs which is weird and my legs itch. What do you think I have? How do you know? How do you treat it?

- Diptheria (bacterial pharyngitis) - Horse serum antitoxin and PCN - remove membrane - Vaccine

I have a sore throat, a weird grey tenacious membrane on the back of my throat, rhinorrhea, fatigue and a fever. What do I have? How do you treat it? How do you prevent it?

- Oxygenated (oxygenated in placenta --> IVC) - NOT oxygenated

Is blood in the fetal IVC oxygenated or not? Is blood in the fetal SVC oxygenated or not?

- Varus - Metatarsus varus - Positioning in uterus - No treatment if flexible, serial casting if rigid - Hip dysplasia

Is this foot abnormality varus or valgus? What do you call it? What causes it? How do you treat? What can be associated with it?

A cyanotic

Left sided lesions - cyanotic or acyanotic?

- Brain tumors - astrocytoma > glioblastoma - Brain MRI - Dexamethasone and surgical removal - Favorable outcomes for the tumor, but cranial radiation can cause long term effects

Mother brought two years old child to pediatric office due to the forehead headache that had lasted for three weeks. In last few days she had vomited in the morning but had some abdominal complaints at the same time. Physical and neurological study showed no clinical abnormalities. The doctor advised the mother to give some pain relief and closely follow the course of the headache. At first the medication helped, but vomiting persisted. When she came back in, a thorough eye exam was performed and papilledema was visualized. What are you concerned is going on? What type is more common? How do you image? How do you treat? Is prognosis good?

30%

Neonate GFR is ________% of adult value.

B. 2

Once heart looping is complete, how many chambers does the developing heart have? A. 1 B. 2 C. 3 D. 4

Cushions don't fuse so your heart does not have four different chambers - all the blood mixes.

Persistent atrio-ventricular canal - what's the problem?

- "hole in your heart" you have a hole between your atria that should have closed all the way, but didn't. Most of the time pressure in LA>RA, so all is dandy but if RA pressure goes up (coughing, Valsalva) unoxygenated blood from LA goes to RA - Present in 25% of people

Persistent foramen ovale - what's the problem? Is this common?

- Your aortopulmonary septum failed, so you have on single arterial vessel (gives rise to systemic, coronary and pulm circulations) - Cyanotic

Persistent truncus arteriosus - what's the problem? Cyanotic or acyanotic?

Too much pressure on left side (likely from mitral or aortic stenosis), closing foramen ovale too soon - then blood from right can't mix with left.

Premature closure of the foramen ovale - what's the problem?

Hodgkin's lymphoma

Reed-Sternberg cells - suspected diagnosis?

*S*leep disturbance *I*nterest decreased *G*uilty feelings *E*nergy decreased *C*oncentration (up or down) *A*ppetite (up or down) *P*sychomotor function (agitation) *S*uicidal ideation

SIG E CAPS - what is this and what is it used for?

15 minutes

Status epilepticus is a seizure lasting ______ or longer.

Rheumatic fever

Sydenham chorea (squirmy arms) - suspected diagnosis?

False

T/F - an females are at a higher risk of unintentional injury.

False - nightmares occur during REM

T/F - night terror occur during REM

Four problems: 1. VSD 2. Pulmonary stenosis 3. Right ventricular hypertrophy 4. Overriding aorta Cyanotic

Tetralogy of Fallot - what's the problem? Cyanotic or acyanotic?

- 3 - 4

The penis grows in length at tanner stage ______, it grows in width at tanner stage _______.

- avoid physical injury (wear seatbelt, helmet, avoid guns), practice safe sex, don't drink, don't smoke, eat healthy and exercise - risk behaviors - psychosocial assessment

Think of all the things they tell you to do/not to do when you are a high schooler - can you list six different ones? What are these all called? What is critical in treatment?

- Colic - GI upset - Nope, other possible causes are sleep issues or "state regulation disorder" - Normal part of development and should be getting better any minute now (typically by 3 months it start to improve) - Go on a drive, sit on dryers, try a swingy chair - Consider acid blocker (liquid zantac) - refer to peds GI, consider mom completely cutting out breast milk or special hypoallergenic formula

This 4 month old, suspiciously brown haired (??), gal looks like she has been crying A LOT, because she has. Her mom tells you it seems like she is never relaxed and always seems uncomfortable and fussy. Otherwise very healthy she cries for 3 hours every day most days of the week. Her mom wants your opinion because it's been going on for two months! What is this? What system is this typically attributed to? Has this been proven? What do you tell mom? What are some techniques to decrease the fuss? How would you treat if she had obvious GI upset?

- Brachial plexus birth palsy - Erb (C5-6) and Klumpke (C7-T1) - Erb - shoulder weakness, elbow extension and wrist flexion - Many heal on their own, PT/OT if persistent, surgery if not resolved by 9 months old

This baby has a "waiter's tip posture." What causes that? What are the two types? What type does he have? How do you treat?

- Reye Syndrome - Hepatic failure and encephalopathy - Aspirin use after viral infection - Monitor and supportive care - Monitor intracranial pressure - irreversible neuro complications can occur

This is a 6 year old child who appears to be recovering from an upper respiratory infection when he develops vomiting. He may have taken aspirin (given by his grandmother), but he was supposed to have taken acetaminophen for symptomatic relief. He was doing well for a couple days but now he is in the ED with agitation and restlessness. He subsequently develops convulsions which are treated with anticonvulsants, and he is admitted to the ICU. What is this? What are two key parts of the diagnosis? What causes it? How do you treat? What do you need to carefully monitor?

- Scoliosis - *standing* AP x-rays - Cobb angle >10 degrees - Idiopathic (80% of cases) - If <20 degrees, observe. If 20-40 degrees, brace. If >40 degrees, surgery. - Age and amount of growth left

This stylish 15 year old gal in her AE jeans and puka shell necklace went to her little brother's well child visit because their pediatrician was so cool. As she was walking away from her pediatrician with her mom, brother and sister, her very observant provider noticed her walk was a bit funny. When she looked closer, she saw this... She denies any pain. What's going on? What is your next step? What measurement do you need to do to diagnose and what is the cut off? What caused this? How do you treat? Other than degrees of curve, what determines treatment?

Child abuse - forced feeding

Torn frenulum without clear cause - concern?

- Your aorta and pulmonary artery are switched - aorta forms from right ventricle, pulmonary artery from left ventricle - Most mixing in the atria - Cyanotic

Transposition of the great vessels - what's the problem? Where does the mixing happen? Cyanotic or acyanotic?

- Tricuspid valve does not develop and there is a ventricular and atrial septal defect. If VSD is small, the right ventricle is completely skipped = hypoplasia. - Right to left blood mixing = *cyanosis*

Tricuspid atresia - what's the problem? Cyanotic or acyanotic?

True - neonates are sensitive to CNS depressants, babies have died from narcotics in breast milk

True or false - a mother using pain medications is a contraindication for breast feeding.

- Imperforate anus - Surgery - colostomy ASAP, depending on the type, perforation or surgery - Low lesions have 90% active continence rates, high lesions have only 30%

Uh oh! What do you call this? How do you treat? Doe low or high lesions have better future outcomes?

- Talipes equinovarus - Idiopathic, neurogenic, associated with other dx - Arthrogryposis and Larsen syndrome - Spine - Refer to peds ortho for serial castings - Surgery is performed in 15-50% of cases

Uh oh! What is this? What are the three categories? In the third, what diseases are associated with it? What other exam is important if you see this? How do you treat? Do they do surgery?

- There is a hole in the ventricular septum so blood mixes from left to right - most close spontaneously at birth. - Membranous is close to the valves (most common), muscular is lower

Ventricular septal defects - what's the problem? Membranous vs muscular?

- Flows caudal to cranial - Veins are lower portion (caudal - toward), arteries are upper portion (cranial - away)

What anatomical direction does the mesodermic heart tube's blood flow? What does this indicate about the anatomy?

- N. meningitidis, S. pneumoniae, H.flu - Vancomycin + ceftriaxone

What are the "big 3" of bacteremia in kids? What antibiotics covers all three?

- MVA - alcohol

What are the majority of unintentional injuries in adolescents? What is associated in 2/3 of the cases?

Aorticopulmonary septum and embryonic ventricular septum

What are the two embryologic features that produce the ventricular septum?

*H* home/health *E* education/employment *A* activity *D* drugs *D* depression *S* safety *S* sexuality

What does HEADDSS stand for?

- Meconium ileus - Thick, water poor meconium due to poor pancreatic enzymes and Cl movement in gut - Whether or not there is intestinal perforation - Enema and bowel irrigation

What is a complication of *cystic fibrosis* that presents as progressive abdominal distention in the hours after birth and bilious emesis? Also presents with a *"ground glass"* abdominal XR. What is that? What categorizes it as complicated vs uncomplicated? How do you treat?

Otolargygologist

What is an important referral after the diagnosis of bacterial meningitis?

- parasomnia involves abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep (think night terrors, sleep walking, etc) - dyssomnia is difficulty falling asleep or staying asleep - consistency and safety

What is the difference between parasomnia and dyssomnia? What is important about kids and sleeping?

Unintentional injury ex: MVAs, poisonings, drownings

What is the largest contributor to causes of death in adolescents (ages 10-19)?

Brain tumors

What is the most common solid tissue cancer in kids?

- Ductus arteriosus - Ligamentum arteriosum

What is the name of this fetal structure (green arrow)? What does it change to in a newborn?

- Ductus venosus - Ligamentum venosum

What is the name of this fetal structure (green arrow)? What does it change to in a newborn?

- Umbilical arteries - Medial umbilical ligament

What is the name of this fetal structure (green arrow)? What does it change to in a newborn?

- Umbilical vein - Ligamentum teres

What is the name of this fetal structure (green arrow)? What does it change to in a newborn?

- Foramen ovale - Fossa ovalis

What is the name of this fetal structure (yellow arrow)? What does it change to in a newborn?

- Torticollis - Shortening of SCM - Left side (chin away, head toward affected side) - Gentle stretching and positioning - surgery is rare - Symmetry and c-spine issues can persist

What is this kink in the babies neck? What is affected? Which side is affected? How do you treat? What if you don't treat?

Atrial septal defect

What is this?

Coarctation of the aorta

What is this?

Tetralogy of Fallot

What is this?

Transposition of the great arteries

What is this?

Ventricular septal defect

What is this?

- Patent ductus arteriosis - Acyanotic

What is this? Cyanotic or acyanotic?

- spina bifida - T12 or S2 - Always genetic, usually associated with folate deficiencies - Cognitively normal but learning disabilities

What is this? What levels does it typically present? What causes it? What long term effects?

Do you have an active plan?

What is your next question when an adolescent tells you they have had suicidal thoughts?

85%

What percent of youth homocides are associated with the use of firearms? A. 20% B. 74% C. 85% D. 93%

2

What tanner stage do breast buds form?

4

What tanner stage do nipple and areola separate and protrude?

3 - yes

What tanner stage does pubic hair darken? Is this the same in boys and girls?

- %H2O - Greater drug distribution

When it comes to neonates, everything is decreased or slowed except _________ which is higher than their adult counter parts. What does this impact?

- increase ampicillin - decrease acetaminophen

When prescribing ampicillin to a pediatric patient, you should _________________ your dose, when prescribing acetaminophen you should _____________ your dose (compared to adults)

In the distal aortic arch - this is important because the blood from the pulmonary artery is relatively oxygen poor and it enters the aorta after the oxygen rich blood from the left ventricle goes to the brain from the branches of the aorta

Where does the ductus arteriosus dump blood? Why is this location important?

A. ASD is not part of it Overriding aorta is missing

Which of the following is not a component of tetralogy of fallot? A. ASD B. VSD C. Pulmonary stenosis D. Right ventricular hypertrophy BONUS: Which on is missing?

E. All of the above

Which of the following structures is part of fetal circulation? A. Ductus venosus B. Umbilical vein C. Ductus arteriosus D. Foramen ovale E. All of the above

- left is valgus, right is varus - Varus is normal through 2-3 yo - Consider rickets or dysplasia - Valgum is normal through 3-8 yo - If unilateral or painful

Which one is varum and which one is valgum? Which one is normal through infancy? What should be suspected if they have the other at 1 yo? Which one is normal in childhood? When should you seek treatment regardless of age?

C - toddlers

Who has the fastest renal elimination? A. Neonates B. Infants C. Toddlers D. Children

A - neonates

Who has the lowest GFR? A. Neonates B. Infants C. Toddlers D. Children

Lower muscle mass = irregular absorption

Why are IM medications tricky in neonates?

- Rheumatic fever - Joint pain, carditis, nodules, eryythema marginatum, and sydenham chorea (squirmy arms) - Fever, prolonged PR interval, arthralgia, elevated CRP/ESR - Need two major or one major and two minor - Bed rest until temp and resting pulse have decreased (also when ESR and CRP decrease if labs available). Treat with PCN G, ASA.

You are doing an international rotation in Nigeria and you are seeing a 6 year old boy for a new rash and bumps under his skin. You also find out many of his joints hurt, and he has been really squirmy recently. His mom says he was sick 2 weeks ago, but got better. What are you concerned is going on? What are the 5 major criteria? What are the 4 minor criteria? How do you diagnose? How do you treat?

- Autism spectrum disorder - See DSM for specifics - *Persistent deficits in social interactions, and two or more restricted and repetitive patterns of behavior/interests*. Symptoms must be present in early development, cause significant impairment, and not better explained otherwise. - You don't - they are all the same diagnosis in DSM - 18 months and 24-30 mos - use ASD screening tools - Refer for behavioral intervention and possible pharm (stimulants, antipsych, SSRIs)

You are doing your family medicine rotation and a 3 year old girl is brought in by her parents due to language delay. She has said a handful of individual words, but no phrases. Does not make effort to communicate non-verbally. As a baby she was very well behaved and quiet. She was interested in stuffed animals and blocks, but avoids engaging with other kids. Mom is worried how she will do in preschool What do you think is going on? How do you diagnose? How do you diagnose this vs Aspergers? When do you screen? How do you treat?

- Combination of four cardiac abnormalities (pulm stenosis, large VSD, overriding aorta, RVH) due to anterior deviation of the infundibulum septum - Listen to that murmur! - Palpate for thrill, check for cyanosis - Surgery by 2 yo

You are dong your rotation in family medicine. Looking at the schedule, you see a 6 day old newborn is on the schedule (!!). Using Care Everywhere, you review his chart from Legacy, where he was born. You see the diagnosis of Tetralogy of Fallot and think, hm, we learned about this in ped.... What was that again? What PE are you going to do first? What other things will you look for? When discussing treatment, when should he have surgery by?

- attachment disorder - Irregular support system - DSM 5 - emotional withdrawal + social disturbance + history of insufficient care + >9 mos and <5 yo old - Continue providing a caring and supportive environment - symptoms may persist for several years but should improve

You are meeting with a 3 year old foster child and his caregiver of 6 months. The caregiver tells you he sits in his room and cries constantly, but when she tries to comfort him he runs away. During the visit, he is sitting in the chair across the room from his caregiver and doesn't answer questions and has a stern affect. What is this? What can cause it? How do you diagnose? How do you treat?

- Pharyngitis - viral (mono) - Bed rest, tylenol for fever and avoid contact sports - Don't kiss or share drinks with people

You are seeing Lara, a 10 year old girl, for an illness that is not resolving. She was prescribed amoxicillin three days ago for tonsillitis with a neg rapid antigen strep test in clinic at that time. Throat culture results are in and confirm she is negative for group A beta‐strep. She now has a swollen, tender lymph node in her axilla and a truncal and proximal extremity non‐purutic rash. This is her 5th day of fever. What do you think is going on? How do you treat? Patient education?

28 days

You are super concerned if a baby less than _________ old has a fever.

- Atrioventricular septal defect - Yes, heart defects are common in infants with Down syndrome - Echo provides definitive dx (FYI it is routine to perform a screening echo on all kiddos with Down syndrome in the first month of life - you don't need a wonky EKG) - Corrective surgery

You just see a 1 month old girl with Down syndrome. Her mother and father report she is doing well. As a routine exam, you perform an EKG and see extreme left axis deviation and 1st degree heart block. What is going on? Is this common in this population? How do you definitively diagnose? How do you treat?

- Pneumonia - RSV or s. pneumoniae - difficult to distinguish - Not typically in distinguishing viral vs bacterial, but can help with diagnosing pneumonia - Viral is supportive, bacterial is ampicillin or amoxicillin - Vaccination!

You see a 10 month old with fever, cough, and *tachypnea*. She was sick with a virus a week or so ago, but she keeps breathing really fast. PE reveals crackles and decreased breath sounds. What do you think this is? What typically causes it? Does a CXR or WBC help? How do you treat? How do you prevent?

- Bronchiolitis - RSV - Mostly clinical - can run RSV - No abx - wash hands because contagious

You see a 10 month old with one day of fever, runny nose, and cough. Her mom brought her in because now she is wheezing, not eating as much and breathing different. PE reveals wheezing and crackles on auscultation. What is likely going on? What causes this? How do you diagnose? How do you treat?

- Non hodgkin lymphoma - Lymphoblastic lymphoma - Bone marrow biopsy

You see a 10 year old boy with facial swelling, and venous engorgement. No shortness of breath. It has rapidly gotten worse over the last few days. What are you worried is going on? What type? What is required to make the diagnosis?

- Ventricular septal defect - CXR can show cardiomegaly/pulmonary artery dilation - EKG can show LVH - Because he is symptomatic, surgical closure

You see a 12 year old boy for "blue lips." His mom brought him in when she thought he had just had a blue Slurpee, but he denied any ingestion of blue delicious drinks. Physical exam reveals cyanosis of the lips, you hear a split S2 with a harsh pansystolic murmur. What do you think is going on? How do you diagnose? Is it large or small? How do you treat?

- conduct disorder - Overlap with ADHD, substance abuse, learning disabilities, family dysfunction, etc. Many present with exposure to domestic violence. - DSM 5 - repetitive pattern manifested by the presence of 3 red flags (from the categories of aggression, destruction, deceitfulness, or serious rule violation) in the last 12 months, one of which has to be in the last 6 months - Optimize school and home environments (multi-systemic therapy), inpatient tx if severe, increase involvement in scouts, team sports, etc.

You see a 12 year old boy with a history of ADHD with is mother. She is bringing him in after she received a call from the school principal that he was pinching classmates hard enough to leave a bruise. When you talk about this he rolls his eyes and says "yeah but they deserved it." At home, he has thrown a controller at the TV while playing video games due to anger, which subsequently broke the TV screen. When asked about these the TV incidence, he denies it. His mom tells you this has gotten much worse after she left her husband, the patient's father, due to domestic violence directed toward her, but not their children. What is this? What causes it? How do you diagnose? How do you treat?

- Tension (most likely) - No disability, or n/v - Yes, >15/month - Preventative (what started at the beginning of the school year? does she need glasses? a new teacher?) or medications

You see a 12 year old girl for recurrent headaches. They happen every morning after first period. She tells you they started at the beginning of the school year. She denies nausea, vomiting or disability. What type of headache is this? How do you know it isn't a migraine? Are they chronic? How do you treat?

- Acute diarrheal illness/ gastroenteritis - Rotavirus - Supportive - fluids, don't use antidiarrheals or pepto - R. rickettsii from tick bites - Doxycycline

You see a 14 month old baby in clinic. Dad tells you baby started going to day care for a few hours per week. He has been doing well, but Sunday (after being in daycare Friday), the baby had sudden onset vomiting, followed by low grade fever, and watery diarrhea. What is this? What likely caused it? How do you treat that? What bug (that comes from a bug!) can also cause GI upset? How do you treat that?

- Juvenile rheumatoid arthritis - Diffuse joint pain in one or more than six weeks - Oligoarticular (<4), polyarticular (>5), systemic, enthesitis-associated - Oliogarticular - Systemic - First line NSAIDs, second line methotrexate

You see a 14 year old boy with a low grade fever lasting one month. He does not have any cough, dyspnea, chest pain, palpitations, weight loss, night sweats, dysuria, hematuria, abdominal pain, loose stools, constipation, rashes..... but does have myalgia and joint pain. He has a history of pain and swelling in his joints which will disappear and reappear. He treats with tylenol which is kinda effective. PE reveals palpable spleen, tenderness, warmth and swelling at the left ankle, left knee, and right PIP joints. What is going on? How do you know? What are the four types? Which is most common? Which one is associated with a salmon colored rash? How do you treat?

- Not track, likely septic arthritis from N. gonorrhea - Joint aspiration (gram stain and culture) and bone scan (rule out osteomyelitis) - <4 mos = group B Strep or S aureus - 4 mos - 4 yrs = H flu and S aureus - 5 yrs - adol = S aureus and S pyogenes (if adolescent, consider gonorrhea) - IV abx targeted at suspected bug for 2-4 weeks (in kids, nafcillin + 3rd gen ceph)

You see a 16 year old boy from penile discharge. After spending 25 minutes in the office visit talking about STIs and safe sex practice, he mentions he also has knee pain he thinks is because of running track. You recheck his vitals and notice his temperature is 99.9 degrees. Do you think his knee pain is really because of running track? What do you think is going on? How do you diagnose? What is the likely bug if he was <4 mos old? 3 years old? 5 years old? How do you treat?

- Tibial torsion - Laxity of the knee joint - Observation - it should get better with age - The *vast* majority get better, so if it doesn't refer to ortho for surgical consult

You see a 2 year old girl who is pigeon toed. Her hips are completely normal. What is causing it? What is that? How do you treat? What if it doesn't?

- UTI - E. coli - others are Klebsiella and Enterococcus - Cath urine culture - No, in young children nitrates are typically negative - Amox, TMP-SMX or first gen cephalosporin

You see a 3 month old female, previously healthy. She has had a high fever for 2 days. Mom denies rash, URI, cough, tachypnea, vomiting and diarrhea. She has been feeding less, but is still wetting diaper. Baby is fussy, but consolable. CBC shows elevated WBC, catherized UA shows elevated WBC. What do you think this is? What bug typically causes it? How do you diagnose? Are nitrates positive? How do you treat?

- Pyloric stenosis - Imaging - good US eval - Rehydrate and refer for surgery - Weakness, feeble and failure to thrive

You see a 3 week old boy with non-bilious projectiles postprandial vomiting. He continues to feed, but also vomits. You palpate a small olive shaped mass in the upper abdomen. What is this? How do you diagnose? What if it isn't treated?

- Acute myelogenous leukemia (AML) or acute lymphoblastic leukemia (ALL) - ALL > AML in kids (so AML is less common) - Bone marrow biopsy - AML - Chemo followed by stem cell transplant - Risk of infection and bleeding - Although uncommon in kids (25%), one third of deaths from leukemia in kids and teenagers are due to AML

You see a 3 year old boy for pain after falling off of the couch. PE reveals axillary petechiae, and irritability. CBC shows elevated elevated WBC and ESR. You prescribe ibuprofen and codeine for toxic synovitis. However, he returns to you one week later with the same symptoms. What two diagnoses are you concerned he has? Which is less common in kids? How do you tell the difference? You see *auer rods* - what do you think it is? How do you treat it? Complication/risk? Why are we studying this this week?

- Wilms tumor - Kidney tumor - US or CT - Surgery + chemo/radiation - 90%

You see a 3 year old healthy looking little girl. Dad tells you they were playing in the pool and when he lifted her up he felt something off in her belly. You palpate a large mass in the left aspect of the abdomen. What do you think is going on? What is that? How do you diagnose? How do you treat? What is the cure rate?

- Nursemaid's elbow - PE and history - xray not helpful - Fast extension, supination and flexion - hear it pop back in place with sudden pain relief - Recurrence - treat with bracing if happens again

You see a 4 year old girl in urgent care. She is guarding her right arm and does not reach out for a sticker you hand her. Her mom tells you she was playing with her cousins and suddenly started crying. What do you call this? How do you diagnose? How do you treat? Long term risk?

- Yeah, in this case it is likely bacterial pharyngitis (strep) - Rapid strep - Still culture - Eradicate acute infection and prevent rheumatic fever - penicillin or amoxicillin

You see a 5 year old boy brought in by his mother for a "strep test." She tells you he has had a sudden onset fever, sore throat and sleepiness. You palpate his cerival lymph nodes and he tells you it hurts. Do you think it is really strep? What is your first test? What if it's negative? How do you treat?

- Femoral anteversion - Vast majority resolve on their own - external rotation exercises like bike riding or skating can help - Nope, bracing usually doesn't help

You see a 5 year old who has continued to walk "pigeon toed" - what is the suspected cause? How do you treat? Do they need bracing?

- Volvulus - Incomplete bowel rotation occurring during 7th to 12th weeks of gestation - Emergent surgical detorsion

You see a 7 day old infant in the ED. Mom tells you starting a day or two ago he started having bright green/yellow vomiting with rapid deterioration. XR reveals "spiral sign" What is the diagnosis? What is that? How do you treat?

- Hirschsprung disease - Nerves do not migrate to anus as they should - Typically genetic - Digital rectal test (rectal manometric testing) will produce large projectile stool - Pick up the phone and call the surgeon - Sepsis

You see a 7 month old. Mom tells you he had relatively normal, but soft, stool until they started him on solid foods last week. Now she has stomach swelling and has not had any stool. When asked, mom denies any large dark, black or greenish-black, thick, tarry, sticky bowel movements during the first two or three days of life. What is the suspected diagnosis? What is that? What causes it? What PE test can you do? How do you treat? What is he at risk of?

- Congenital hip dysplasia - Ortalani - out and up! - Allis sign - uneven hips - First month of life - after that it gets trickier to catch - Find orthopedic surgeon for bracing and surgery

You see a baby for her two week well child visit. She is all wrapped up in mom's arms. Even though she looks so comfy, you do you due diligence and perform a hip exam. While rotating in and pushing down, you hear a thunk! What is the likely diagnosis? How do you thunk it back? What is another sign you can look for? When is it best to catch this pathology? How do you treat?

- Transposition of the great arteries - There is a large ventricular septal defect - He would be severely cyanotic at birth - it would have been caught earlier - Echo to diagnose - CXR and EKG will not help - Surgery

You see a one week old baby for his first well child. His mother tells you his lips have been getting more and more blue, especially when crying. She has also noticed he has been breathing fast. What could be going on? Because he has been fine for a week, what is the likely comorbid pathophys? What if that wasn't the case? How do you diagnose? How do you treat?

- oppositional defiant disorder - Caregiver dysfunction and history of multiple care givers - DSM 5 - four sxs of anger, irritability, defiance or vidictiveness + associated distress in loved ones + no psychosis, depression, substance use or bipolar - Support parenting skills, screen for comorbid dx

You see a six year old girl brought in by her adoptive mother. She tells you she is worried be she has been out of control for the last 6 months. She is constantly throwing temper tantrums, arguing, and breaking rules. Even when she is caught, she blames others on it - even the dog! In the visit, the child is angry, constantly disagreeing with her mother and say "UGH!" about 15 times. She has not hurt anything or anyone. Her adoptive mother tells you her biological mother (she was adopted at age 4) has a history of drug abuse and schizophrenia. What do you think is going on? What causes this? How do you diagnose? What if it's unclear? How do you treat?

- Legg-Calves-Perthes disease - Late stage - No bracing or surgery - watch and wait and it will revascularize and the femoral head will regrow

You see an 11 year old male who jokes he is the "runt" of his class. He is limping and he denies pain from the limp, but notes a persistent pain that just wont go away. You perform an x-ray and see the following. What is this? Is this early or late stage? Does bracing help? Do you need to do surgery?

- No, it is a general seizure - must have temp >39 degrees to be febrile - No, must have two seizures separated by at least 24 hours or a single seizure associated with 60% recurrence rate - Febrile seizures are more common - EEG and MRI - No workup other than rule out other causes (ex: meningitis). Treat underlying illness + diazepam

You're on your ER rotation. You see a 20 month old boy who was brought in by his parents for a seizure. He awoke this morning with a fever of T 38.7°C axillary and was again treated with Tylenol. However, as his parents were getting him dressed, David started having "full body shaking with jerking of both his arms and legs". The movements were rhythmic and he seemed "out of it". His eyes were stared straight ahead, and parents did not notice any facial or mouth movements. He was still wearing his diaper, so they are unsure of any bowel/bladder incontinence. They did hear some grunting, but there was no change in his colour. The entire episode lasted about 1 minute and David was sleepy afterwards. He is now back to his normal behavior. Is this a febrile seizure? Is it epilepsy? Which is common? What is your workup for an unprovoked seizure? How do you workup/treat a febrile seizure?

- adolescent girls - boys - firearm

_______________ make up 3-4x as many suicide attempts, but _______________ make up 3-4x as many completed suicides. What is the most common form of completed suicide?