Smarty PANCE Pediatrics

A 9-year old girl is brought to the clinic by her mother on account of fever. She has red skin lesionson the trunk and proximal extremities, and also small, non-tender lumps located over the joints. On further enquiry, she reports a history of sore throat which occurred about 4 weeks ago. Antistreptolysin O titer is positive.

Acute Rheumatic Fever

A 3-year-old previously healthy male is brought to your office by her mother. The mother reports the child has been crying and pulling at her right ear over the past 2 days and reports the patient has been febrile the past 24 hours. The patient's past medical history is unremarkable, although the mother reports the patient had a "common cold" a week ago, which resolved without intervention. His temperature is 101.6 F, blood pressure is 100/70 mmHg, pulse is 120/min, and respirations are 22/min.

Acute otitis media

A 7-year-old boy is brought to his pediatrician for evaluation of a sore throat. The sore throat began 4 days ago and has progressively worsened. Associated symptoms include subjective fever, pain with swallowing, and fatigue. The patient denies cough or rhinorrhea. Vital signs are as follows: T 101.4 F, HR 88, BP 115/67, RR 14, and SpO2 99%. Physical examination is significant for purulent tonsillar exudate; no cervical lymphadenopathy is noted.

Acute pharyngotonsillitis

A 13-year-old boy with clear fluid discharge from his nose for 2 days duration. This has also been associated with sneezing. On nasal exam, the mucosa and turbinates appear edematous and slightly bluish. He has swollen dark circles under his eyes and a transverse nasal crease.

Allergic Rhinitis

A 15-year-old girl with type 1 diabetes mellitus and hypothyroidism presents to the emergency department because of sweating, shaking, and palpitations. This morning she was asked to deliver a speech for a class assignment. She states that she suddenly started to fear that she would make a mistake and her classmates would start laughing at her. The onset of symptoms began shortly after. Her blood glucose and thyroid studies are all normal.

Anxiety disorders

A 14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient's mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremity, RLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leukocytosis with a shift to the left.

Appendicitis

A 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes.

Asthma

A 5-year-old child presents with an occipital headache, an ataxic gait, nystagmus, and papilledema

Astrocytoma

A 5-year-old girl brought in by her mother for an itchy rash on her antecubital fossa, wrist, hands, ankles, and feet. Her mother describes the rash as severely itchy & "thick looking." Her father had asthma as a child. On PE, you noted a pruritic, xerotic, and lichenified rash on theantecubital fossa, wrist, hands, ankle & feet

Atopic dermatitis

A healthy 7-year-old girl who has reached all developmental milestones. On examination, the precordium is hyperdynamic with a prominent right ventricular heave. A grade III/VI systolic ejection murmur is present in the 2nd left intercostal space (pulmonic position) with an early to mid-systolic rumble and fixed splitting of the second heart sound (s2) during inspiration and expiration.

Atrial Septal Defect

A 3-year old with a firm inflamed swelling in the right submandibular area. Initial medical management with intravenous antibiotics was ineffective. Fine needle aspiration of the lesion reveals acid-fast bacilli on Ziehl-Neelsen staining. Subsequent biopsy demonstrates a granulomatous reaction in keeping with a Mycobacterial infection. Specific questioning reveals no family history of tuberculosis, abscesses or infections; there are no family pets, no exposure to birds and no unpasteurised milk consumption. An initial chest x-ray was normal and Mantoux testing was negative. Conventional anti-tuberculous therapy (Isoniazid, Rifampicin, and Pyrazinamide) is commenced. Definitive culture at 6 weeks isolates Mycobacterium avium intracellulare. The prescription is altered to include Clarithromycin.

Atypical mycobacterial disease

A 3-year-old boy is brought to your office by his mother due to abnormal behavior. She reports that he does not appear to respond to affection, does not look her in the eyes, and constantly lines up his toys. He becomes agitated when she tries to take him away from his toys or if the mother cooks a different meal for dinner. On physical examination, he does not respond to questions and is distracted by the texture of the exam-table cloth.

Autism Spectrum Disorder

A 6-year-old who comes to the clinic with limp and left knee pain. He is notably short for his age. The pain is worse after soccer practice and exacerbated by internal rotation of his hip. At times the pain is severe enough that he refuses to walk. His temperature is 37.1°C (98.8°F), pulse is 102/min, respirations are 24/min, and blood pressure is 102/74 mm Hg. A hip radiograph is obtained and shows the left proximal femoral epiphysis to be misshapen and more horizontal compared to the unaffected right hip, the femoral head appears collapsed.

Avascular necrosis of the femur

A 3-year-old with fatigue, irritability, and a low-grade fever that he has had for 3 days. According to the patient's mom, the child attends a daycare where a virus is "going around." On physical examination, the child does not look ill. His temperature is 98.6 F (38 C). His skin examination shows scattered, small vesicles on an erythematous base. The rash was seen first on the face and seems to be spreading to the trunk.

Chickenpox / Varicella

A 9-year-old girl who you are seeing for a wellness checkup. The girl's past medical history is non-contributory, and she has met all her developmental milestones. Her parents were recently called into the office as the girl was found touching the genitals of one of her classmates. The girl is asked what has happened and what she thinks is going on but she is too shy to reply. The girl and her mother recently moved in with a family member. They live in low-income housing subsidized by the government and are currently on food stamps. The mother states that her daughter has been particularly argumentative lately and that they have gotten into arguments in which her daughter screamed at her and locked herself in the bathroom

Child abuse and neglect

An 8-year-old boy who is seen for the first time in your office. His parents report that he tires easily and often complains of weakness in his legs.Physical exam shows a healthy boy with a blood pressure of 141/91 mmHg. You notice that his lower extremities are slightly atrophic with a mottling appearance. Upon further examination, he is found to have very weak and delayed femoral pulseswith a blood pressure of 96/60 in the lower extremities. He has a late systolic ejection murmur on cardiac auscultation. CXR is performed demonstrating a "figure of 3 sign"

Coarctation of aorta

A 23 day old newborn that is brought to the emergency department with a chief complaint of extreme fussiness. His parents think he has abdominal pain as he is "gassy" and pulls his legs up as if he is trying to stool. He passes a lot of gas from his rectum and his parents can hear his stomach gurgling a lot. Tonight's episode has lasted for 4 hours withintractable crying, and his parents are very distraught. They have tried feeding, a pacifier, rocking, burping, changing the diaper, and inserting a rectal suppository but nothing has relieved the crying. He is currently feeding a standard cow's milk formula with iron without vomiting or diarrhea. Further questioning reveals this is the fourth day in a row that this has happened on a daily basis, usually in the evening, but the baby usually cries for about 2 to 3 hours.

Colic

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated Manifested by the presence of at least three of the following 15 criteria in the past 12 months. From any of the categories below with at least one criterion present in the past 6 months.

Conduct disorder

A 4-month old female with asymmetric thigh creases during a routine checkup. Physical exam reveals that the left lower limb is shorter than the right and lay externally rotated. Hip abduction is limited to 30 degrees. Ortolani's test is positive producing a soft "clunk" with anterior relation of the femoral head into the acetabulum. Radiographs reveal a superiorly displaced left proximal femoral metaphysis and a shallow, hypoplastic left acetabulum. The infant is treated in a Pavlik abduction harness for congenital hip dislocation.

Congenital hip dysplasia

A 6-year-old boy complaining of itchy eyes. The mother states that she has noted that he has been tearing up and that both of his eyes have been red for the past 4 days. The patient denies any pain but has had a runny nose for the past week. The mother states that he has not had any sick contacts, and he has been home from school for summer vacation. On exam, there is marked redness, tearing, and eyelid edema in both eyes.

Conjunctivitis

A 5-year-old boy with no significant medical history. His mother explains to you that since starting kindergarten earlier in the year, he has been having progressively worse periodic abdominal pain. When he has this pain he is cranky, refuses to eat, and has even vomited on a few occasions. She also explains that since starting school he has been having regular soiling accidentsdespite successfully potty training over a year ago.

Constipation

A 10-year-old boy with a bright pink and itchy rash with a linear pattern on his forearm and the dorsum of his left hand. He states that 4 days ago he went to a wooded park with his family. Several hours later, he noticed that his forearm and the back of his hand are red and itchy. He reports that last summer he had a similar incident when he went to the same park. On PE, a pink patchy rash with a linear pattern is noted on his forearm and the dorsum of his hand. Clear vesicles are also noted within the patches

Contact dermatitis

A 2-year-old boy who is brought to you by his father who is concerned about a "barking cough," mild fever, and a hoarse voice. He reports that he had a runny nose last week that has since resolved. Physical exam reveals inspiratory stridor

Croup

A one-year-old child who is brought to your office for his 12-month visit. You note that the boy's testicles are inappreciable on the exam. The medical record reports that the child's testicles had been examined at two previous visits. The mother is very concerned and asks if her son will need surgery.

Cryptorchidism

A 3-year-old girl with growth retardation has a long history of recurrent pneumonia and chronic diarrhea. Her mother states that he has 6-8 foul smelling stools per day. Physical exam reveals a low-grade fever, scattered rhonchi over both lung fields, crepitant rales at the left lung base and dullness to percussion. Other findings include mild hepatomegaly and slight pitting edema of the lower extremities. CXR reveals hyperinflation, mucus plugging, and focal atelectasis. Labs reveal an elevated quantitative sweat chloride test.

Cystic Fibrosis

A 10-year-old girl who comes to the clinic with her mother because of dysuria and suprapubic pain for the past two days. She is usually healthy, has received her childhood immunizations, and has had no previous episodes of this kind. Physical examination is normal. Urinary dipstick is positive for leukocytes andnitrites.

Cystitis

A 12-year-old girl is brought by her parents to the emergency department with diffuse abdominal pain. She has no significant past medical history. Over the past month, the patient has lost several pounds despite a greatly increased appetite. She has also wet the bed several times in the past month and insists on drinking over 3 gallons of water per day because she is so thirsty. The patient is breathing rapidly and very deeply. Her abdomen is tender to palpation in all four quadrants with no rebound. The remainder of her examination is normal.

DM

A previously healthy 11-year-old boy presents to the emergency department with a 3-day history of nausea, anorexia, weakness, abdominal pain, and an episode of vomiting. He has no history of fever, diarrhea, constipation, respiratory or urinary symptoms, or use of laxatives or diuretics. Physical examination reveals a thinly built boy with signs of sunken eyes, slightly dry mucous membranes, and generalized skin hyperpigmentation. He is afebrile, with a capillary refill time of less than 2 seconds, blood pressure of 94/68 mm Hg, and a heart rate of 116 beats/min. His weight is 32 kg (70.5 lb) (weight loss of 6% in the previous 3 days).

Dehydration

A 16-year-old is brought to your office by her parents because they are concerned that she is acting differently. She is quiet and denies any changes in her personality or drug use. The parents step out of the room at your request and she begins crying. She states that school has been very difficult and has been very depressed for the past 6 months. She feels tremendous pressure from her parents and coaches. She says that she has been cutting her wrists for the past week and is planning to commit suicide. She instantly regrets telling you and begs you not to tell her parents.

Depressive disorders

A 2-month-old healthy baby boy who presents to your office with his mom complaining of a rash in the diaper area for three days. She applied Monistat cream topically 5 days ago, and the rash cleared up but has now returned. On physical exam, you note an elevated, erythematous rash in the diaper area with satellite pustules

Dermatitis (diaper, perioral)

A 10-day-old infant boy is brought to the office for an evaluation. Physical examination shows epicanthal folds, a broad nasal bridge, a large tongue, small ears, hypertelorism, Brushfield spots, a single palmar crease on each hand, and a harsh holosystolic murmur.

Down syndrome

A 3-year-old male who presents today with his mother with c/o rash that started 2 days ago. His mother states that he had an ear infection and was treated with amoxicillin 6 days prior. On physical exam, you note a non-pruritic rash covering his chest and extremities

Drug eruptions

A 2-day-old preterm (33 weeks), weighing 1.3 kg neonate with upper abdominal fullness. A nasogastric tube drains bilious aspirate. The external genitalia and anal opening are normal. Further evaluation by X-ray flat plate abdomen shows a "double-bubble appearance" with a total absence of distal bowel gas.

Duodenal atresia

A 14-year-old boy with three days of sore throat, fever, and generalized malaise. On exam, he has a temperature of 102.2 F (39.0 C), BP 96/50, and a diffuse exudate on both tonsils. He is also noted to have palpable splenomegaly, swollen, painful lymph nodes, and mild hepatomegaly. Labs show leukocytosis of 12,000/mm3 with 50% neutrophils, 12% monocytes, and 38% lymphocytes. The rapid pharyngeal streptococcal screen is negative.

EBV

A 6-year-old boy whose mom reports "my son keeps having accidents in his underwear. He's 6 years old. Shouldn't he be old enough to know better by now?"

Encopresis

A 5-year-old boy who comes to the emergency department because of enuresis for 1 month. His mother says he recently started kindergarten and is afraid he will have an accident during nap time. He stopped wetting the bed for almost 2 years and then suddenly started again with no recent change in diet or fluid intake. He has no history of daytime incontinence.

Enuresis

A 6-year-old child presents with an occipital headache, an ataxic gait, nystagmus, and papilledema

Ependymoma

A 3-year-old boy who is brought to the ER with a sudden onset of fever (104.0 F), respiratory distress, and stridor. On examination, the boy appears acutely ill. He is sitting, leaning forward with his mouth open, he has a muffled voice and is drooling. When asked the parents report "we don't believe in vaccinations."

Epiglottitis

A 14-year-old who is brought to your Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleeding. In the ED, a topical vasoconstrictor is tried but also fails to stop the bleeding.

Epistaxis

"Slapped cheek" rash on face

Erythema infectiosum (fifth disease)

A 12-year-old boy who presents with some non-itchy maculopapular rash that looks like targets. He stated that a week ago, he was treated for an HSV infection. On PE, you note a symmetrical red rash with 3 areas of concentricity which are red, white & purplish in color respectively.

Erythema multiforme

Pain often accompanied by fever, often mimics an infection. May have palpable mass, swelling, and local tenderness X-Ray: appears as a lytic lesion with an onion-skin appearance of the periosteum

Ewing's sarcoma

A 3-year-old boy is brought to the emergency department due to a generalized tonic-clonic seizure. The seizure lasted about 3 minutes. His temperature was measured to be 103.2°F. He has no prior history of seizures.

Febrile seizure

A 17-year-old female who is in your office for an annual sports physical. She is the star of her high school track team. She has not menstruated for 5 months. Her BMI is 15 kg/m2. On physical exam, you note calluses on the back of her hands and fine hair on her arms. She states that she only eats vegetables but has been trying to cut back as she thinks she is holding excess body fat.

Feeding/eating disorders

A 4-year-old boy with unilateral purulent, foul-smelling nasal discharge for three days. The child has no other respiratory symptoms.

Foreign body

A 5-year-old boy is brought into the emergency department after he was found at home by his father possibly drinking bleach stored in the laundry room. The child consumed an unknown amount and appears generally well. The child has an unremarkable past medical history and is not currently taking any medications. Physical exam reveals a normal cardiopulmonary and abdominal exam. The neurological exam is within normal limits and the patient is cooperative and frightened. The parents state that theingestion happened less than 30 minutes ago.

Foreign body

A 3-month-old who presents with his mother for a WCC. The patient consumes 4 ounces of cow's milk formula every three hours. He stools once per day, and urinates up to five to six times per day. His mother reports that he regurgitates a moderate amount of formula through his nose and mouth after most feeds. He does not seem interested in additional feeding after these episodes, and he has become progressively more irritable around meal times. The patient is starting to refuse some feeds. The patient's weight was in the 75th percentile for weight throughout the first month of life. Four weeks ago, he was in the 62nd percentile, and he is now in the 48th percentile. His height and head circumference have followed similar trends.

GERD

A 4-year-old boy is brought to the urgent care for 48 hours of watery diarrhea. He had been attending daycare 3 times a week, and several other kids have also experienced similar symptoms. He has had 4-5 bowel movements per day and has had a decreased appetite. His parents have been encouraging him to drink electrolyte solution. On physical exam, he is noted to have sunken eyes, poor skin turgor, and increased capillary refill time.

Gastroenteritis

A 5-year-old female is brought to the office by her mother because of "coke colored" urinefor a day. Three weeks ago, she was given antibiotics for impetigo. Past medical history is noncontributory. Her temperature is 36.5°C (97.7°F), pulse is 72/min, respirations are 14/min, and blood pressure is 134/86 mm Hg. Urine microscopy demonstrates dysmorphic erythrocytes and red blood cell casts. The result of a 24-hour urine collection is 2.6 g of protein/24 hr.

Glomerulonephritis

Children < 10 years old caused by coxsackievirus type A virus producing sores in the mouth and a rash on the hands, feet, mouth, and buttocks (watch video

Hand-foot-and-mouth disease

A 2-month-old infant presents for a routine health maintenance visit. The mother has been concerned about the infant's hearing since birth. Physical examination reveals no apparent response to a sudden loud sound.

Hearing Impairment

Excess bleeding ↑ PTT, normal PT, and platelets, with ↓ Factor VIII or IX on assay

Hemophilia

A 3-month-old girl with jaundice and clay-colored stools x 15 days. She was born full-term, and there were no antenatal or postnatal complications. Her milestones were normal for age. On examination, weight is 4.3 kg (<3rd percentile), length is 54 cm (<3rd percentile), and head circumference is 39.5 cm (1oth percentile). You note icterus and hepatosplenomegaly.

Hepatitis

A 27-year-old female who complains of exquisite vulvar pain and blisters. She reports that she has experienced several similar episodes for the past 5 years. On examination, you find multiple painful vesicles on her left labia minora. You recall that on a previous visit, she had a positive chlamydia culture that was treated with azithromycin tablets.

Herpes Simplex

A 2-week-old boy with constipation. His mother reports that he has not had a bowel movement for over 5 days and is quite concerned. On further examination, you discover that the boy is in the 5th percentile for weight. Physical examination shows a distended abdomen. Rectal examination shows anabsence of stool in the rectal vault. A contrast enema reveals dilated loops of bowel and megacolon.

Hirschsprung Disease

A premature infant who is born at 30 weeks and after several hours develops rapid shallow respirations at 60/ min, grunting retractions, and duskiness of the skin. The chest X-ray reveals diffuse bilateral atelectasis, ground glass appearance, and air bronchograms

Hyaline membrane disease

A 1-day-old male infant born by normal spontaneous vaginal delivery was found to have a scrotal mass on physical examination. The mass transilluminates and confirms your suspicion of hydrocele.

Hydrocele

A 2-week-old infant who is brought to the office for evaluation. He was born at 36 weeks gestation and weighs 2.6-kg (5.7-lbs). His temperature is 38.8˚C (101.8˚F), his heart rate is 184/minute, and his respirations are 55/minute. Physical examination shows that he appears unusually alert and agitated and has exophthalmos. There is aprominent goiter and a relative lack of subcutaneous fat over the rest of his body. His mother was diagnosed with Graves disease during her second trimester of pregnancy and was managed with methimazole.

Hyperthyroidism

A 25-year-old woman presents the ER after a syncopal episode. She had a loss of consciousness 3 times over the past 12 months. Each event occurred during or just after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and an III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. The EKG shows a normal sinus rhythm with diffuse increased QRS voltage.

Hypertrophic Cardiomyopathy

A healthy newborn male is undergoing routine examination, upon examination of the genitalia the urethral meatus is found located proximal to the tip of the glans on the ventral aspect of the penile shaft.

Hypospadias

A 3-month-old infant of immigrant parents is brought to the pediatrics clinic because of intermittent choking, constipation, lethargy, hoarse cry, and a suspicion that she is "floppier"than other babies since her birth. The patient is in the 15th percentile for heightand 25th percentile for weight. Physical examination reveals an infant with a protuberant abdomen, dry skin, dry, brittle hair, and a low hairline. Parents report that her birth was normal.

Hypothyroidism

A 5-year-old girl with crusting facial lesions present for 3 days. The mother reports that prior to the development of the facial lesions her daughter was scratching at insect bites. Examination reveals a red facial rash with a golden "honey-colored crust" and pruritus.

Impetigo

A 5-year-old with sudden onset of fever, chills, malaise, sore throat, headache, and coryza. The child is also complaining of myalgia, especially in her back and legs. On physical exam, the patient appears lethargic, has a temperature of 102.5 F, and palpable cervical lymph nodes. Breath sounds are distant with faint end-expiratory wheezes

Influenza

A 25-day old boy presenting for his well-child checkup. He was born at 39+6 to a 28- year-old mom who had been followed by this clinic for her prenatal care. Prenatal history was unremarkable. During his first few weeks of life, he has been exclusively breastfed and is now well above his birth weight. Mom has no major concerns and appears to be doing well but did notice abulge in her son's right inguinal area when changing his diaper yesterday. Your exam was unremarkable except for a notable bulge in the patient's right scrotum and inguinal area.

Inguinal hernia

A young mother who brings her 12-month-old daughter to your office reporting that she has had recurrent "belly aches" for the past two weeks. The child experiences sudden, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting. These episodes are interspersed with periods of no complaints. The mother also reports that she has seen her squatting with her knees to her chest, which seems to relieve her of her symptoms. She describes her stool as bloody with mucus, almost as though it were a currant jelly. On physical examination, you note abdominal distention and tenderness along with a sausage-shaped abdominal mass in the RUQ.

Intussusception

A 3-day old baby boy is brought by his mother for his first postnatal visit. He was born via vaginal delivery at 39.2 weeks with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. The mother's pregnancy was uncomplicated. He stayed in the well-baby nursery for two nights and was discharged without incident. On physical exam, the neonate appears lethargic with a soft, open fontanelle and soft abdomen. His skin is notable for a yellowish tinge. Mom is exclusively feeding him breastmilk for 5-10 minutes every 4 hours. At birth his weight was 7lbs 6oz and his current weight is down to 6lbs 8oz.

Jaundice

A 14-year-old with complaints of morning stiffness and fatigue for the past 3 months. She complains of worsening stiffness after periods of inactivity and finds it difficult to participate in sports, especially PE. Her mom is particularly concerned because her daughter has been missing school and this has begun to affect her academic performance. They are requesting a medical note to be dismissed from physical education.

Juvenile rheumatoid arthritis

A 5-year-old boy presents to the emergency room with 5 days of fevers, ranging from 102-104°F (38.9-40°C). His mother reports that he also has a bad rash that developed on day 3. On physical exam, he has bilateral conjunctivitis, an extensive morbilliform rash on his trunk with desquamation, a bright red tongue, and swollen hands andfeet. Labs are remarkable for elevated C-reactive protein, white blood cell count, and erythrocyte sedimentation rate. He is immediately given intravenous immunoglobulin and aspirin and sent for an echocardiogram.

Kawasaki disease

A 9-year-old boy who was brought to the clinic by his mother on account of a 5-month history of abdominal cramps, bloating, diarrhea, and flatulence that occur usually about 2 hours after ingesting milk

Lactose intolerance

A 4-year-old boy is brought to the emergency department by his parents because of severe abdominal pain and constipation for 2 days with no improvement. Prior to this episode, his mother states that he has become increasingly irritable and lethargic over the past 2 weeks to the point where he has stopped speaking. Review of the patient's medical history shows that he failed to meet developmental milestones over the past year. When asked about this, the parents mention that he has been having a hard time adjusting since they moved into an older home with many of the original fixtures 15 months before. Physical examination of the patient shows marked lethargy and is otherwise normal.

Lead poisoning

A 10-year-old girl brought in by her mother after she was picked up from school for excessive scratching of her hair. She reports that the itchiness has been ongoing for 1 week. On PE, you note several ovoid, grayish-white eggs less than 1cm from the base of the hair shaft at the back of the head and behind the ears.

Lice

Appears as purplish, itchy, flat-topped bumps. On mucous membranes, such as in the mouth, it forms lacy white patches, sometimes with painful sores Clinically characterized by 5 Ps ⇒ purple, papule, polygonal, pruritus, planar

Lichen planus

A 10-year-old boy with otalgia, worsening over the last 5 days and associated with nasal congestion. The patient is afebrile with a temperature of 98 ° F. Examination reveals edema of the external auditory canal, producing an anterior and inferior displacement of the auricle with percussion tenderness posteriorly.

Mastoiditis

Cough, coryza, conjunctivitis, and cephalocaudal spread Morbilliform - maculopapular, brick red rash on face beginning at hairline then progressing to palms and soles last - rash lasts 7 days Koplik spots (small red spots in buccal mucosa with blue-white pale center) precedes rash by 24-48 hours.

Measles (Rubeola)

A 6-year-old child who is brought to the emergency room for a complaint of high fevers and a rash. His mother reports that she thought he had "just a cold" approximately one week ago—he had a mild fever, runny nose, conjunctivitis, and cough. Then he developed a rash that started on his face and gradually spread downward. The child has no significant past medical history, however, he was adopted from Russia at age 5, and his medical history prior to adoption is unknown. On examination, the child appears lethargic and has a temperature of 104.3. There is a mild injection of his conjunctiva and a generalized macular rash. White macules are noted on his buccal mucosa

Measles / Rubeola

A 5-year-old boy presents to his pediatrician with headache, nausea, and 2 episodes of emesis. His symptoms began approximately 1 month ago, and his headache is most prominent in the morning. The patient also reports some mild fevers and chills. On physical exam, the patient has a wide-based gait with impaired heel-to-toe walking. Fundoscopy demonstrates bilateral papilledema. An MRI brain with intravenous contrast demonstrates a heterogenous midline lesion with hydrocephalus.

Medulloblastoma

A 10-month-old boy presents to the ED for several days of irritability and poor feeding. The patient has no significant past medical history and has received all routine preventative care. His temperature is 102.5°F,blood pressure is 57/40 mmHg, pulse is 172/min, respirations are 34/min, and oxygen saturation is 98% on room air. During the exam the infant is irritable and is crying. Musculoskeletal exam reveals that the patient's knee can not be extended while the patient's hip is in a flexed position without significant patient irritation. The rest of the exam is within normal limits.

Meningitis

A 5-year-old male is brought to the clinic with acute onset of painful swollen parotid glands. His mother reports that he was fine last night, but awoke with the swelling this morning. He has no significant past medical history, but it is documented in his chart that his mother declined the recommended standard immunizations for children because of personal beliefs. On examination, the child appears well and has a temperature of 100.8 F. His right parotid gland is slightly more swollen than the left, but they both are markedly swollen and tender.

Mumps

A 12-year-old boy who is brought into your clinic by his father for sunburns that have not been healing. The father states that he easily gets sunburned. His father admits that he and his partner have never taken the child to see a doctor. The patient walks with a wide stance gaitand appears unstable on his feet. He has an extensive erythematous, scaling, hyperkeratotic rash on his face, neck, arms and legs

Niacin deficiencies

A 3-year-old boy is brought to the clinic because of left elbow pain. The father of the patient says that after picking up the boy from daycare, he noticed his son was not moving his elbow andcomplained of pain. Patient is holding his left elbow flexed and pronated. Physical examination shows tenderness over the lateral aspect of the left elbow joint on palpation.

Nursemaid elbow

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictivenesslasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

Oppositional defiant disorder

A 10-month-old boy with friable white plaques on the tongue that bleed when scraped.

Oral candidiasis

A 2-year-old who arrives at the ED with a swollen and erythematous eyelid, proptosis, pain with movement of the eye, and an inability to adduct or abduct his eye

Orbital cellulitis

A 14-year-old boy with left knee pain. He denies any trauma to the knee. The patient runs cross country for his high school team and attends practice regularly. On physical exam, the tibial tubercle is pronounced and there is tenderness to palpation over the affected area. The patient reports pain upon resisted knee extension

Osgood-Schatter disease

Benign chondrogenic lesion derived from aberrant cartilage - the most common benign bone tumor mostly in males ages 10-20 years old X-ray: sessile (broad base) or pedunculated (narrow stalk) lesions found on the surface of bones

Osteochondroma

Progressively worsening night pain, bone pain/joint swelling - may look similar to growing pains and can be easily missed X-ray: sun ray/burst or hair on end appearance followed by bone scan look for metastasis

Osteosarcoma

A 4-year-old girl who is brought to the clinic by her mother, who states that the child has been complaining of progressively worsening ear pain and itchiness over the past week. Examination reveals left tragal tenderness and an edematous and closed canal. Weber lateralizes to the left.

Otitis externa

Entrapment of the foreskin in the retracted position

Paraphimosis

A 2-week-old infant with a history of prematurity presents with a pink torso and upper extremity and blue lower extremities. On cardiac auscultation, you notice a rough, continuous "machinery murmur" heard over the left sternal border at the 2nd intercostal space (pulmonary area).

Patent ductus arterioles

A 19-year-old male who you are seeing for follow-up from the urgent care where he was seen 2 days earlier with a sore throat. The patient is febrile (102°F), has amuffled (hot potato) voice, and extreme difficulty opening his mouth (trismus). He opens it just far enough for you to note uvular deviation.

Peritonsillar abscess

Foreskin in normal position that cannot be retracted

Phimosis

A 4-year-old is brought to the office by his mother because the daycare teachers noticed he is unusually restless at school. The mother also noticed that he has not been sleeping well lately and has started wetting the bed at night. The child is alert and cooperative butscratches his buttocks while you are interviewing. Cellophane tape applied to the perianal areareveals football-shaped ova under the microscope.

Pinworms

A 15-year-old female with a 3-week history of oval eruption that aligns along the skin folds. She states that a week ago she noticed a 3 cm oval patch with central clearing on her upper thigh. A week later, smaller variants of the initial patch started to erupt. On PE, a wide-scale symmetrical papular eruption is noted over her trunk. Lesions align along the Langer lines in a characteristic Christmas tree pattern.

Pityriasis rosea

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. (mycoplasma pneumonia)

Pneumonia

A 6-week-old first-born baby boy with projectile vomiting after feedings over the last 24 hours. Mom says that he enjoys feeding, and even after he vomits, he appears eager and hungry. On physical exam, you palpate an olive-shaped mass in the epigastric region at the lateral edge right upper quadrant. Labs show blood pH 7.47 and potassium of 3.2 mmol/L. On a barium upper GI series report, the radiologist states a "string sign" is present.

Pyloric stenosis

A 5-month-old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Nasal flaring, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes and a cough are present.

RSV

A 3-year-old child presents strabismus. His mother notes that sometimes of family photographs it appears that one eye is white while the other is red.

Retinoblastoma

A mother who brings her 8-month-old infant into the clinic with a complaint of high fevers for three days. She denies any other symptoms. On examination, the child appears very well and is playful with you despite having a temperature of 103.9 F. A complete physical examination and urinalysis are done, and no source of the fever is found. You send her home with fever control measures and a follow-up appointment for the next day. The next day, the child is afebrile but has a generalized pink maculopapular rash.

Roseola

Herpesvirus 6 or 7, only childhood exanthem that starts on the trunk and spreads to the face High fever 3-5 days then rose pink maculopapular blanchable rash on trunk/back and face

Roseola (sixth disease)

A mother who brings her 14-month-old daughter for evaluation of a rash. The mother describes the rash as beginning on the face and subsequently spreading to the rest of her body over one day. She also reports that her daughter has a mild fever and redness in her eyes. She has not been vaccinated per her parents' preferences. The temperature is 100°F (37.8°C). There is mild bilateral nonexudative conjunctivitis, postauricular lymphadenopathy, and petechiae on the soft palate and uvula. Pink maculopapules are found in the face, neck, trunk, and extremities. The rash disappears in three days.

Rubella

"3-day rash" pink light-red spotted maculopapular rash first appears on the face, spreads caudally to the trunk and extremities, and becomes generalized within 24 hours (lasts 3 days) Cephalocaudal spread of maculopapular rash, lymphadenopathy (posterior cervical, posterior auricular)

Rubella (German measles)

An 8-year-old male is brought to the emergency department with oral ulcers and a rash on his hands and feet that has worsened over the last 48 hours. The rash now covers less than 10% of his total body surface area, characteristic of Stevens-Johnson Syndrome. The patient has a history of epilepsy and was started on phenytoin 10 days ago. He also has a fever of 101°F and is visibly distressed due to pain. Vital signs show BP 110/70 mmHg and HR 130.

SJS

A 12-year-old boy who presents with c/o excessive itching in the interdigital spaces of the hands and feet, axillae, and groin. The head and neck are spared. He reports that his brother came home last week from school with itchiness and was later diagnosed with scabies. On PE, you note linear burrows and excoriations in his web spaces of hands and feet, axillae & groin. Lesions do not appear to be infected.

Scabies

A 13-year-old girl who is being seen in your office for a routine well-child exam. She denies back pain and states she began her menses 3 months ago. On Adams forward bending asymmetry in scapular height is noted. She has 5 of 5 motor strength in all muscle groups in her lower extremities and symmetric patellar and Achilles reflexes. You obtain standing PA and lateral radiographs.

Scoliosis

A child exhibits short staring spells at school, which are sometimes accompanied by loss of postural tone. Episodes last less than a minute. Electroencephalography reveals bilateral 3-Hz spike-and-wave pattern.

Seizure disorder

A 16-year-old girl who comes to the clinic because of pale spots on her skin as well as multiple moles scattered across her body. She is short and also has a webbed neck andmultiple melanocytic nevi across the face, back, and limbs that are about 1-5 mm in diameter. Additionally, she has other well-circumscribed areas that appear depigmented.

Short stature

A 7-16 y/o obese male during a growth spurt with a limp and knee pain with external rotation of affected the leg

Slipped capital femoral epiphysis

A 3-year-old girl brought to you by her mother, who is worried about her daughter's "lazy eye."She reports that her daughter's symptoms are exaggerated when she has a cold. Past medical history is negative for trauma or headaches. The patient has an asymmetric corneal light reflex, and the cover/uncover test reveals a right-sided esotropia. You refer the patient to a pediatric ophthalmologist.

Strabismus

A 19-year-old female college student is brought into the emergency department by her boyfriend. The boyfriend reports that the patient got caught cheating on a college exam and was expelled. The boyfriend received a text that evening saying "I'll miss you." When he arrived at her dorm room, the patient was slumped next to her bed covered in blood. The patient agreed to be driven to the emergency room. When asked about what happened, the patient replies "I just want out of this life." The patient has bipolar disorder, and takes lithium as prescribed. She has a school psychiatris that she sees every week. She has never had a prior suicide attempt nor has she ever been hospitalized for a psychiatric disorder. The patient's vitals are stable.

Suicide

A 6-year-old female presents to the emergency department with a 3-day history of fever and sore throat, followed by painful, erythematous skin lesions that have rapidly progressed over the past 24 hours. The mother reports that her daughter was started on a course of sulfamethoxazole-trimethoprim for a urinary tract infection 5 days ago. On physical exam, you estimate the lesions cover ~ 20% of her body surface area. Vital signs show BP 100/60 mmHg and HR 120.

TEN

A 6-month old girl is brought by her father for a scheduled check-up. The patient's father says they recently started feeding her mushy cereal, which she seems to like but occasionally spits up. He also reports that she has started teething and sometimes becomes "fussy." Vital signs are within normal limits. You note a happy appearing child with an "open mouth look" and drooling.

Teething

A 15-year-old boy with severe lower abdominal pain that awoke him from sleep about 3 hours ago. The pain is sharp and radiates to the left thigh. While in the emergency room, the patient experiences one episode of vomiting.He denies any fever, dysuria, or chills. The mom reports a childhood history of cryptorchidism. Physical examination reveals normal vitals with blood pressure 100/60 and a temperature of 98.6F. The abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender. Lifting of the left testicle does not relieve pain and there is a loss of a cremasteric reflex. Transillumination test is negative. Doppler ultrasound shows absent blood flow.

Testicular torsion

A 2-week-old newborn brought to the ER by his mom who reports a sudden loss of consciousness during feeding and with crying. She also has noticed that the infant's lips have turned blueon three occasions during feeding. blood pressure is 75/45 mmHg, a pulse is 170/min, and respirations are 44/min. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal border. A CXR shows a small boot-shaped heartand decreased pulmonary vascular markings.

Tetralogy of Fallot

A 16-year-old female presents for evaluation of delayed onset of menstruation. She is concerned as her friends have all had their first menese. She denies any additional significant PMHx. On physical exam, her temperature is 98.8°F, blood pressure is 114/64 mmHg, pulse is 73/min, and respirations are 13/min. The patient is short statured, has a short neck and wide torso. You note webbing skin between the neck and shoulders. She has Tanner stage I breast development and pubic hair with normal external female genitalia. On bimanual exam, the vagina is of normal length and the cervix is palpable.

Turner syndrome

A 9-month-old female with nasal congestion and cough is brought to your clinic by her mother, who reports that the child is very fussy, has been tugging at her right ear, and refuses to eat. On physical exam, you note copious green/yellow nasal discharge and right-sided otorrhea. An otoscopic exam reveals a significant amount of clear/white discharge obstructing your view. With careful examination, you are able to observe a ruptured right tympanic membrane

Tympanic membrane perforation

An otherwise-healthy 7-month old female infant brought to the clinic by her mother on account of a 3-month history of umbilical swelling which is usually more apparent when she cries. On examination, the swelling was reducibleand a defect was felt through the umbilicus.

Umbilical hernia

A well-appearing 9-month-old male with a rash that comes and goes. According to the mother, citrus was recently added to the patient's diet. On physical exam, you observe a widespread rash composed of blanchable, edematous, pink papules, and wheels on the face, trunk, and lower extremities. The patient is started on PRN oral antihistamines for pruritus, and the mother is encouraged to eliminate citrus from his diet. The rash resolves within 72 hours

Urticaria

A 4-year-old boy who is brought to your office by his parents because he gets tired very easily and cannot keep up with the other children. On exam, you hear a loud, harsh, holosystolic murmur at the left lower sternal border without radiation to the axillae.

Ventricular Septal Defect

A 9-year-old girl with multiple lesions on her hands and feet. She reports that these are not painful or itchy, but they are very embarrassing. Her best friend will no longer hold her hand and refuses to come to her house for a sleepover. Her past medical history includes atopic dermatitis. On physical exam, she has multiple 4-5 mm flesh-colored, sharply demarcated, rough, round, and firm nodules on her hands and feet.

Verrucae

A 1-year-old female with a temperature of 103.1 and irritability. A culture of a urine specimen is obtained and shows more than 106 colony-forming units of pansensitive Escherichia coli per milliliter. She is treated with intravenous ampicillin for several days, followed by oral ampicillin, for a total of 14 days of therapy. After the patient no longer had a fever and a urine culture was sterile, voiding cystourethrography was performed while the patient was still receiving ampicillin. The voiding cystourethrogram demonstrates bilateral grade III vesicoureteral reflux, and renal ultrasonography revealed normal findings.

Vesicoureteral reflux

A 3-year-old girl is brought to your office for a routine checkup. She was recently adopted and her past medical history is unknown. The patient's parents state that she was very emaciated when they adopted her and noticed she has trouble seeing in the evening. They also note that she was experiencing profuse foul-smelling diarrhea as well, which is currently being worked up by a gastroenterologist. Her temperature is 98.3°F, blood pressure is 106/64 mmHg, pulse is 104/min, respirations are 17/min, and oxygen saturation is 99% on room air. The girl appears very thin. She hasdry skin noted on physical exam.

Vitamin A deficiency

A 13-year-old boy who presents with a rash. He is accompanied by his mother who first noticed red dots on his skin last week that have been spreading over the last few days. The patient's mother notes that his gums have begun to bleedafter brushing his teeth and he has been sleeping more than usual. He has not been ill recently or received any vaccines. The boy had an unremarkable birth history and was diagnosed with autism spectrum disorderat age three. He is primarily nonverbal and attends a school for children with special needs. Exam reveals a thin boy who avoids eye contact and does not respond to verbal questions. Cardiopulmonary exams are unremarkable. The hair on his arms is coiled. The child's leg shows diffuse petechiae on the leg and you note gingival hemorrhage.

Vitamin C deficiency

A 5-year-old who presents to your office for an initial visit. The child just immigrated from Africa and is now living in his new home. The patient is small for his age and is in the 5th percentile for height and 10th percentile for weight. His parents are concerned as the child has complained of leg pain and chest pain ever since he fell off the monkey bars at school. A radiograph of the chest demonstrates expansion of the anterior rib ends at the costochondral junctions and a radiograph of the legs demonstrates genu varum. The cardiac and pulmonary exam are within normal limits.

Vitamin D deficiency

A 9-year-old boy who is brought by his mother after the child was suspended from school for being disruptive during class. The teacher noted that the patient is always fidgeting, has difficulty concentrating, and does not complete assignments. His mother notes that he often gets up and runs around the house when she is trying to call everyone for dinner and that this has been going on since he was 6 years old.

ADHD

CHILD + Lymphadenopathy + bone pain + bleeding + fever in a CHILD, bone marrow > 20% blasts in bone marrow

ALL

Smear Auer rods Symptoms usually develop less than 4 weeks before diagnosis Initial symptoms include lethargy, malaise, and anorexia 25% of children develop bone pain or arthralgia caused by leukemic infiltration of the perichondral bone or leukemic expansion of the marrow cavity

AML

A 4-week-old baby boy brought in by his mother with c/o of a red rash on the sides of his face. She states that the rash has been present for a week now. It does not appear to itch at this time. On PE, you note comedones, and papules on the lateral aspect of his face.

Acne vulgaris

A 9-month old infant presents with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C (101.4 F), and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Flaring of the alae nasi, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes are present.

Acute Bronchiolitis