Pediatrics Test 3: GU, NEURO, CV

Syncope Management

- Education and reassurance - Overhydration - Increase sodium - Avoid caffeine - Exercises and compression stockings - Medical: • Fludrocortisone (mineralocorticoids) • Betablockers

Syncope Evaluation

- History: w/wo exercise; precipitating events, presence of "prodrome", duration of unconscioussness; CPR - Family history: HCM, CHD, SD, arrhythmia (long QT syndrome) - PE: • BP and HR in supine and standing position - Ancillary tests: • ECG • Treadmill • Head tilt table testing (rare!!)

Cardiac causes of Chest Pain

- Myocardial • HCM, DCM, AS - Coronary ischemia: • Kawasaki disease, anomalous coronary arteries • Substance abuse (cocaine) - Pericardial disease • Pericarditis - Aortic dissection (Marfan syndrome) pectus exavatum

Chest Pain Non cardiac • Reassuring features may include:

- No murmur - No palpitations - Reproducible with exam (tenderness at costochondral points)

Chest Pain Non cardiac • Reassuring history may include

- Occurs at rest - Last few minutes (sharp) or lasts long hours (dull) - Right sided chest pain - Associated with new activities (weight lifting) - Associated psychological stress - No associated symptoms (syncope/palpitations)

Kawasaki disease

(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.

SYNCOPE Red Flags (probable cardiac cause) chest pain w/syncope or exercise

- Abrupt onset with few or no premonitory sx - Acute collapse with activity or exercise - Need for CPR - PMH: Kawasaki disease w/coronary involvement - Family history of arrhythmia (SVT, AV block); congenital heart disease (AS); cardiomyopathy (HCM)

T: Peripheral Pulmonary Artery Branch Stenosis PPABS Innocent Murmur

0- 1 yo Soft ejectile murmur(systolic) ULSB radiating to axillae Congeital heart defects assoc with maternal Rubella infection

T: Juvenile Myoclonic Epilepsy

12-18 yo healthy kids 50% have FHx of generalized seizures Lifelong disorder Myoclonic Jerks Generalized Tonic Clonic Seizures Absence Seizures Lifestyle: Sleep, Drug/Etoh consumption, Med adherance At risk for cognitive, behavioral, and social difficulties

Testis Tumor is the most common cancer in men aged?

15-35 Risk factors include: Cryptorchidism Trauma Atrophy Typically painless but can present with pain Torsion of neoplasm Infarction bleeding promote testicular examination

Venous hum Innocent Murmur

2-5 Continuous sound Right subclavian area Goes away when lying down Caused by normal sound of blood returning from jugular veins to heart; hence goes away when lying down

Innocent Murmurs

2-57% of infants 6-90% school aged Less than 1% of children have structural cardiac problem 50% of kids will experience one at some point

T: Incarcerated Hernia

2/3 occur in pts < 1yo Irritability anorexia, N/V Abdominal distention groin tender and swollen irreducible may become red as process progresses

CHEST PAIN

2nd CC after heart murmur leading to Cardiac referral 99% of the time not r/t cardiac cause Dx: H&P, FHx, Hx of drug/etoh Additonal testing rarely needed =/- ECG

Still's murmur Innocent Murmur Most Common

3-5 yo Lower Left Sternal Border Vibratory/Musical sound Louder when lying down d/t Left vent contracts forcing blood into aorta

T: Microscopic hematuria

5+ blood cells in centrifuged sample

T: Infantile Spasms

90% onset <1y Development regression Initially infrequent then frequent and in clusters EEG: is hypsarhythmia or chaotic •Seizure description • Sudden, brief contractions of ≥ 1 muscle group (neck, trunk, extremities) followed by a longer, less intense tonic phase • Can be flexor, extensor, or mixed flexor‐extensor • Typically symmetric and synchronous • Can occur in clusters lasting several minutes • Most frequent just after waking, and almost exclusively occur in the daytime • May be followed by motor arrest or decreased responsiveness •Poor prognosis •Early recognition is critical •Differential diagnosis • Colic • GERD (Sandifer syndrome) • Exaggerated/hyperactive reflexes (Moro) • Benign myoclonus of infancy • Shuddering attacks • Benign paroxysmal torticollis

T: UTI Most commonly seen GU issue

<3m: fever>100.4, hypothermia, poor feeding, irritability, vomiting, FTT & sepsis Preschool: abd or flank pain, enuresis, dysuria, fever, irratability, poor appetite, V/D School-aged: dysuria, suprapubic pain, urgency, frequency, abd/flank pain

How does a health care provider diagnose epilepsy? A. History or description of seizures B. A test called an electroencephalogram (EEG) C. A test called positron emission tomography (PET) D. A and B

A and B. One of the most important factors in diagnosing epilepsy is a patient's history of seizures. The EEG may detect brain wave patterns that may indicate seizures. A PET scan may help the doctor find out which area(s) of the brain are affected by the seizures, but it is not necessary for the diagnosis.

epididymis

A long, coiled duct on the outside of the testis in which sperm mature. Causes: underlying urogential anomalies In adults it's gonorrhea or chlamydia Gradual onset of pain Fever Evaluate for positive Prehn's sign (elevation of scrotal sack relieves the pain)

Although the characteristics of a seizure may differ from person to person, seizures are caused by the same thing: A. A sudden change in how brain cells send electrical signals to one another B. A sudden change in how the spinal cord and brain talk to each other C. A sudden change in blood flow in the brain D. A sudden change in oxygen flow in the body

A. A sudden change in how brain cells send electrical signals to one another

When counseling the family of an otherwise healthy 2-year-old child who just had a febrile seizure, you consider the following regarding whether the child is at risk for future febrile seizures: Select all that apply. A. The occurrence of one febrile seizure is predictive of having another. B. Intermittent diazepam can be used prophylactically during febrile illness to reduce risk of recurrence. C. A milder temperature elevation in a child with a history of a febrile seizure poses significant risk for future recurrent febrile and nonfebrile seizures. D. Consistent use of antipyretics during a febrile illness will significantly reduce the risk of a future febrile seizure.

A. The occurrence of one febrile seizure is predictive of having another B. Intermittent diazepam can be used prophylactically during febrile illness to reduce risk of recurrence.

A patient taking phenytoin can exhibit a drug interaction when concurrently taking: A. cyclosporine. B. famotidine. C. acetaminophen. D. aspirin

A. cyclosporine.

T: The preferred urinary tract imaging study for a 22-month-old girl with first-time febrile UTI is: A. renal-bladder ultrasound (RBUS). B. renal scan. C. voiding cystogram (VCUG). D. none unless a second UTI occurs.

A. renal-bladder ultrasound (RBUS).

5.Medications with narrow therapeutic indexes (NTIs) include all of the following except: A. topiramate. B. phenytoin. C. carbamazepine. D. valproate.

A. topiramate.

T: Complex Partial Seizure

Alteration of awareness ◦ Behavioral arrest lasting 30‐120 seconds ◦ Stare into space ◦ Automatisms ◦ Unaware and unresponsive

TB: Benign febrile seizures are characterized by: a. A temperature lower than 39° C b. Respiratory or ear infections c. Onset after the fifth year of life d. Episodes lasting 30 minutes or longer

B. Respiratory or ear infection An acute respiratory or ear infection is usually present. Simple febrile seizures are rare in infants before 9 months of age or in children older than 5 years of age. The convulsion occurs with a rise in temperature higher than 39° C (102.2 °F). The convulsion is short (15 minutes or less).

T: Which of the following is most likely to be part of the clinical presentation of UTI in a 20-month-old child? A. urinary frequency and urgency B. fever C. suprapubic tenderness D. nausea and vomiting

B. fever

he murmur of atrial septal defect is usually: A. found in children with symptoms of cardiac disease. B. first found on a 2- to 6-month well-baby examination. C. found with mitral valve prolapse. D. presystolic in timing.

B. first found on a 2- to 6-month well-baby examination.

A Still murmur: A. is heard in the presence of cardiac pathology. B. has a humming or vibratory quality. C. is a reason for denying sports participation clearance. D. can become louder when the patient is standing.

B. has a humming or vibratory quality.

Myoclonic=

Brief involuntary twitching of a muscle of muscle group

T: In children 2 months to 2 years old with UTI, antimicrobial therapy should be prescribed for: A. 3 to 5 days. B. 5 to 10 days. C. 7 to 14 days. D. 14 to 21 days.

C. 7 to 14 days.

Which is the most common treatment for epilepsy? A. Surgery B. Special diet C. Medication D. An implanted electrical device Submit

C. Medication. Drugs called anti-epileptic or anticonvulsant medications are the most common treatments for epilepsy. These medications can prevent seizures from occurring. They must be taken carefully to maintain the proper level of the drug in the body to prevent seizures. If medication does not work, health care providers may turn to surgery, a special ketogenic diet, or an implanted device that stimulates the vagus nerve leading to the brain.

When choosing an antimicrobial agent for the treatment of UTI in a febrile female child who is 16 months old, the NP considers that: A. gram-positive organisms are the most likely cause of infection. B. a parenteral aminoglycoside is the preferred treatment choice. C. the use of an oral third-generation cephalosporin is acceptable if gastrointestinal function is intact.

C. the use of an oral third-generation cephalosporin is acceptable if gastrointestinal function is intact.

Pericarditis

Cardiac Pain is worse with inspiration JVD Pulsus Parodoxus-exagerated decrease in normal BP with inspiration

T: Indicators for poor prognosis in Childhood Absence Epilespy

Concurrent Cognitive difficulties General-Tonic Clonic Seizures or Myoclonic after onset Absence status epilepticus Abnormal background on initial EEG FHx of generlized seizures in 1st degree relative

CHD =

Congenital Heart disease 34% 0-1 yr BIGGEST RISK GROUP 18% 1-5 yrs 15% 5-10 yr 14% 10-15 yr nearly 50% of kids will have a murmur at some pt.

T: Simple Partial Seizure

Consciousness maintained ◦ Motor: jerking movements 1 pt body, tonic movements ("fencing posture") ◦ Aura: focal seizure w/sensory or psych sx ◦ Autonomic: changes in BP, HR, bowel function, etc

Alcohol can be dangerous for a person with epilepsy because: A. It can interfere with medication used to control seizures B. It can cause seizures C. It can cause a heart attack D. A and B

D. A and B. Alcohol can be dangerous when taken with sedatives such as phenobarbital. Mixing alcohol with these drugs can lead to coma or death. Drinking large amounts of alcohol can increase the risk for seizures. Moderate drinking -- having a drink or two a day -- may or may not affect you.

In some states, if you have epilepsy, you can get a driver's license only if: A. You haven't had a seizure in three months B. You haven't had a seizure in a year C. Your health care provider has written a note saying you are free of seizures D. All of the above

D. All of the above. Each state's regulations are different, but generally they require that you be seizure-free for a specific amount of time before you are allowed to drive. Some states require a health care provider's note. You can safely drive a motor vehicle if your seizures are under control

Although exercise is good for people with epilepsy, some sports are not appropriate. Which of these is/are not? A. Mountain climbing B. Swimming C. Football D. All of the above

D. All of the above. Mountain climbing is risky both because of the danger of falling if you have a seizure and because the thinner air at higher altitudes can put you at greater risk for a seizure. Swimming and other water sports are risky because you can drown if you lose consciousness. Contact sports like football can put you at risk for brain trauma, which can make seizures worse. Other sports to avoid include skydiving and hang gliding. People with epilepsy should not exercise when the weather is very hot, because excess heat and dehydration can trigger seizures.

Which of the following statements about potential drug interactions with phenytoin is false? A. Phenytoin increases theophylline clearance by increasing CYP 450 enzyme activity. B. When taken with other highly protein-bound drugs, the free phenytoin concentration can increase to toxic levels. C. Phenytoin can increase the metabolic capacity of hepatic enzymes, thus leading to reduced drug levels. D. When phenytoin and theophylline are given together, the result is a higher concentration of both drugs than when given separately.

D. When phenytoin and theophylline are given together, the result is a higher concentration of both drugs than when given separately.

T: The urinary tract abnormality most often associated with UTI in younger children is: A. bladder neck stricture. B. ureteral stenosis. C. urethral stricture. D. vesicoureteral reflux.

D. vesicoureteral reflux.

Syndromes with high incidence of Congenital Heart Defect

DOWN SYNDROME: VSD, AVSD DiGeorge syndrome: TOF, IAA Alagille: Peripheral pulmonary artery stenosis NOONAN syndrome: Pulmonary stenosis Williams: Supravalvar AS Turner: Bicuspid Ao valve, CoAo

T: Nocturnal Enuresis Drugs

Desmopressin (DDAVP)- .2mg oral tab at bedtime Oxbutynin Chloride (ditropan) 5 mg bid imipramine (Tofranil) 1-2.5 mg/kg/day at bedtime

Seizures can be caused by: A. Brain injury that left scar tissue or other damage B. Infection that left scar tissue in or caused other damage to the brain C. Exposure to a toxic substance D. Malfunctioning gene E. All of the above

E. All of the above

Epilepsy is most likely to begin in which age group? A. Early childhood B. Adolescence C. Middle age D. Age over 65 E. A, B and D

E. All of the above Epilepsy is often thought of as a childhood condition it can develop at any age About 30% of cases develop in early childhood and adolescence. Over 65 yo is also at higher risk

What is the most common UTI pathogen?

Escherichia coli >85%

T/F The presence of leukocytes in a bagged urine sample is sufficient to diagnose a UTI in a 2 year old.

False Bagged specimens are not useful unless negative

TEST T/F A 12 month old female can be diagnosed with UTI based on presence of nitrites in urinalysis alone

False Need ABNORMAL Urine Culture and UA

Antiepileptic Drugs (AED)

First‐time unprovoked seizure ◦ Typically not treated with AED ◦ Tx witheld until pattern of recurrence determined ◦ Exceptions: ◦ Potential remote symptomatic etiology ◦ Focal seizure with abnormal EEG Second unprovoked seizure ◦ Typically started on AED ◦ Exception: infrequent and/or "mild" seizures

T: UTI risk factors

Girls (2+) Caucasian • Age <12 months • Temperature 39 degrees or greater • Fever 2 or more days • Absence of another source of infection Boys (3+) • Nonblack race • Temp 39 degrees or greater • Fever greater than 24 hours • Absence of another source of infection uncircumcised males

Heart Murmur Intensity Test

Grade 1 = very faint Grade 2 = quiet but heard immediately Grade 3 = moderately loud Grade 4 = Loud (ass. w/thrill) (pathologic) Grade 5 = Heard w/steth partly off chest Grade 6 = no steth needed

Chest Pain Red Flags

Grossly abnormal vital signs • Pain with exercise • Pain preceded by palpitations • Cardiac: - Pathologic murmur, gallop, pericardial rub - Diminished femoral pulses - Persistent/unexplained tachycardia - Presence of HSM, JVD or peripheral edema • Pulmonary: - Focal/absent lung sounds, crackles

Proteinuria Objective findings

Growth and development HTN Edema (especailly periorbital Abdominal exam Heart and lung exam

Headache Management: Prevention

Lifestyle Modifications ◦ Sleep ◦ Nutrition ◦ Stress and psychiatric comorbidities Prophylactic Agents ◦ Most commonly Rx = amitriptyline & topiramate ◦ Goal: 50% change over 3 months

Chest Pain History

Location of pain, severity, exacerbating or alleviating factors, associated symptoms and radiation of pain - PMHx of conditions that may pre-dispose patient to cardiac etiology of chest pain - Fam Hx of early cardiac disease, suddent death and cardiomyopathy in family. Also thrombotic diseases. - Illicit drug use, medications the patient is currently taking

T: Nocturnal Enuresis Etiologies

Maturational delay Genetics is biggest factor-75% if both parents 40% if one Sleep arousal dysfunction- sleep deeper Small bladder capacity- many 5 yo can't hold all nt Urodynamics: maturation of detrusor muscle Nocturnal polyuria Psych factors

Seizure HX

Medical Dx such as DM, CV, Renal Birth trauma or CNS infection Intrauterine infection, trauma or bleeding Toxic exposure or drug use Anticonvulsant drugs stopped abruptly Recent head injury FHx of seizure Missed milestones

T: hypospadias

Most common penile abnormality urethra opening on the undersurface of the penis Circumcision CI Abnormal urinary stream Chordee is assoc. finding Refer to Urology

Rebound Headache

Most likely to least likely to cause NSAIDS Ergotamine Troptans Caffeine containing products Aspirin Opiods Acetaminophen Barbiturates

T: Nocturnal Enuresis Tx

Motivational therapy bladder training fluid management behavioral alarms Pharm Tx - for summer camp & sleepovers

Tics

Motor or Vocal Increase w/focusing on tic, lack of sleep, stress, holding tic in Tourette syndrome onset 2-15 yo, ^w/ADHD, OCD

Cremaster muscle

Muscle that pulls the scrotum closer to the body in cold temperatures and relaxes to let the testicles be farther away from the body in warmer weather

Rescue Headache Management

Naproxen Migraine Naproxen =/- triptan, antiemtetic set limits Naproxen <12 days/month

Seizure and Fever

Nervous system infection underlying seizure disorder febrile seizure

Cardiovascular

Objectives: describe a murmur Innocent murmurs Chest Pain Syncope

Pulmonary flow murmur Innocent Murmur

Older children and teens Soft systolic ejection murmur Upper Left Sternal Border Noticed in Pectus Extravatum or Pectus Carinatum

T: Types of Seizures

Partial (focal) Simple (aware) Complex ( Impaired awareness) Generalized

Pulmonary Flow Murmurs include

Peripheral Pulmonary Artery Branch Stenosis PPABS and Pulmonary flow murmur You are hearing is normal blood flow across a normal pulmonary valve that can produce extra sounds. The pulmonary valve happens to be one of the most anterior structures Therefore it makes sense that you might be able to hear normal flow across this valve compared to the other valves in the heart, which are farther back in the chest. can sound like an atrial septal defect might make a similar noise.

T: Headaches

Primary vs Secondary PQRST of HA Secondary: Acute illness Post‐traumatic HA Medications Hypertension Intracranial Hemorrhage Hydrocephalus CNS Tumor Idiopathic Intracranial Hypertension Medication overuse HA

T: proteinuria

Protein in urine >1+ confirmed 3 occasions 75% of asymptomatic pts will be normal of f/u visit Microscopic for RBC, CASTS = pathologic condition DDx: Orthostatic proteinuria: most common/70% Exercise induced: 2nd most common cause Fever induced benign proteinuria Renal disease is LESS common (nephrotic syndrome or mebranous glomerulonephritis)

T: Febrile Seizure Dx Criteria

Seizure w/temp >100.4 Age: >3m but <6 yrs No CNS infection/inflammation No acute systemic metabolic abnormalities EE No Hx of previous afebrile seizure

SYNCOPE VS SEIZURE TEST

Seizure: hx of seizures aura automatism convulsions at start the loss of consciousness longer duration post-ictal phase tongue biting Incontinence Syncope Triggering factor gradual prodome/dizziness prior to fainting may convulse after faint short duration quick recovery lethargy but no confusion

Status Epilepticus

Single seizure lasting > 30 min OR cluster of seizures w/o return to baseline > 30 min Duration > 5 minutes should be treated as SE •Home rescue therapy • Rectal diazepam • Buccal or intranasal midazolam

Headache Management: Rescue

TTH: naproxen Migraine: naproxen +/‐ triptan, antiemetic Set limits for use ◦Naproxen: ≤12 days/month ◦Triptans: ≤10 days/month

Primary Headaches

Tension Migraine: mestrual related, childhood Trigeminal Autonomic Cephalagias Less common Primary HA

T: Scrotal Pain assess these things

Testis: enlarged? Transilluminate Urethral d/c Prehn's Sign- relieves epididymis Cremaster reflex Labs: UA, CBC, Doppler US

inguinal canal

The most common location of the cryptorchid testis is in the __________.

Describing a Heart Murmur

Timing: Systolic, Diastolic, Continuous Characteristics: Ejection, Holosystolic Intensity: Musical, harsh blowing; low or high pitch Location: Aorta, Pulmonic, Tricuspid, Erbs Pt, Apex Transmission/Radiation: back, axilla, carotids

Testicular Tortion

Twisting of spermatic cord acute onset of pain Hx of trauma or activity SURGICAL EMERGENCY Prehn's Sign sign does not relieve pain Effected testicle sits higher will not cremaster reflex

Test last year: A seven-month old female is brought to your clinic with a three-day history of fever, decreased appetite, trouble sleeping, and some increased crying but easily consolable. There is no history of recent exposure to illness, and no URI symptoms. Although on exam, the temperature is 101.0* F rectally, she is an alert, active infant and the physical exam is normal. Urine dipstick is positive for nitrites and leukocyte esterase What's todays Plan?

Tx with antibiotics while doing C&S test If C&S is positive order renal bladder US

T: cryptorchidism

Types: retractable, ectopic, absent (total) Complications: infertility, tumors

test Proteinuria laboratory

UA first morning sample Protein: creatinine ratio Evaluate for orthostatic proteinuria T: less than .2 is normal so .25 is abnormal

Commonly used drugs for seizures

Valproic acid is 1st line for most seizure disorders can cause wt gain & LF Therapeutic index Valproic 50-100 Phentoin 5-20 Ethosuximide 40-100 Carbamazepine 3-12

T: Y/N Can children outgrow Childhood absence epilepsy?

Yes, most children do outgrow CAE Some end up with Juvenile Myoclonic Epilepsy

T: hydrocele

a fluid-filled sac in the scrotum along the spermatic cord leading from the testicles Translucent upon trans illumination

T: phymosis

a narrowing of the opening of the foreskin so that it cannot be retracted (pulled back) to expose the glans penis can be normal in uncircumcised boys <5 yrs

T: What term is used to identify the condition that exists when the urethral meatus is located on the undersurface of the penis? a. Hypospadias b. Epispadias c. Hyperspadias d. Chordee

a. Hypospadias

Which of the following best describes patient presentation during an absence seizure? a. blank staring lasting 3-50 seconds b. awake state with abnormal motor behavior lasting seconds c. rigid extension of arms and legs, followed by sudden jerking movements with loss of consciousness d. abrupt muscle contraction with autonomic signs

a. blank staring lasting 3-50 seconds

T: cryptorchidism basics

absence of one or both testes from scrotum. most common birth defect male genitals. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis. about 80% of cryptorchid testes descend by the first year of life (the majority within three months), making the true incidence of cryptorchidism around 1% overall.

Postictal=

after the event

Murmur

an extra or unusual sound heard during the cardiac cycle

T: vulvovaginitis treatment

avoid restrictive clothes: leotards, swimsuits avoid chemical irritants: bubble bath Review proper hygiene Sitz baths Tx underlying etiology Refer if abuse suspected Foreign body to ER or Ped Uro

Varicocele

bag of worms not relieved by Phren's sign Result of valvular incompetence of spermatic vein Occurs in 15% of early adolescent males Refer prepubertal boys

T: nocturnal enuresis is considered abnormal after 8yo may go til 10-12 in males

bedwetting Primary=never potty trained Secondary=potty trained for >6m then regressed 1st Sx of DM or UTI

T: hematuria

blood in urine DDx: UTI, pyelonephritis- does child appear puffy perineal irritation, trauma, renal calculi, tumo: Wilms Tumor epididymitis

Which of the following best describes patient presenting with tonic-clonic seizure? a. blank staring lasting 3-50 seconds b. awake state with abnormal motor behavior lasting seconds c. rigid extension of arms and legs, followed by sudden jerking movements with loss of consciousness d. abrupt muscle contraction with autonomic signs

c. rigid extension of arms and legs, followed by sudden jerking movements with loss of consciousness

Neurocutaneous diseases associated with seizures

cafe au lait spots or neurofibromatosis ash leaf spots or adenemo sebaceum of Tuberous Sclerosis

pigmenturia

can be caused by foods like beets and meds

T: What is a common cause of enuresis?

constipation

T: Which statement is false about the causes of enuresis? a. A maturational lag may cause enuresis. b. Enuresis may be related to increased light sleep. c. Obstructive sleep apnea may be a symptom of enuresis. d. Excessive nocturnal levels of vasopressin may cause enuresis.

d. Excessive nocturnal levels of vasopressin may cause enuresis.

Which of the following best describes patient with myoclonic seizure? a. blank staring lasting 3-50 seconds b. awake state with abnormal motor behavior lasting seconds c. rigid extension of arms and legs, followed by sudden jerking movements with loss of consciousness d. abrupt muscle contraction with autonomic signs

d. abrupt muscle contraction with autonomic signs

Treatment options for seizures include all of the following agents except a. carbamazepine b. phenytoin c. gabapentin d. tamsulosin

d. tamsulosin for BPH

Prophylactic Regiments for patients at risk for endocarditis

dental: amoxicillin Unable to take oral meds: ampicillin or Cefazolin/ceftriaxone Pen Allergy: Clndamycin/Cephalexin/Azithromycin

Ictal=

during the event

Indirect inguinal hernia

failure of embryonic closure of the deep inguinal ring after the testicle has passed through it most common cause of groin hernia

Test T/F A positive urine culture is sufficient work-up for a 12 month old with UTI

false Abnormal urinalysis and urine culture are Required forDx.

Seizure PE

focal abnormalities, weakness HTN or renal disease Systemic disease CV disorder Neurocutaneous disease

History: Description of Seizure

focal or generalized Loss of consciousness aura length of postical sleep or confusion duration of episode associated illness incontinece

T: Chordee

head of the penis curves downward or upward Often occurs with hypospadias

T: Generalized Seizure

impairs consciousness and distorts the electrical activity of the whole or a larger portion of the brain absence seizures (formerly known as petit mal) tonic-clonic or convulsive seizures (formerly known as grand mal) atonic seizures (also known as drop attacks) clonic seizures. tonic seizures. myoclonic seizures.

T: paraphimosis send to ER

inability to return the retracted foreskin over the glans. Condition leads to pain and edema treated by circumcision.

T: vulvovaginitis

inflammation of the vulva/vagina usually secondary to infection r/t bad hygiene examine in frog leg position in parents lap

AED Therapy

low and go slow & always taper off Drug toxicity, suicide, SJS, TEN, DRESS Screen for V D and supplement Folic Acid supplement for females & contraceptive

Seizure

misfiring of the cortical neurons causing involuntary contractions of voluntary muscles represent brain dysfunction or underlying issue

orchitis can be caused by the __________?

mumps inflammation of testis assoc. with mumps or GC Fever Urinary symptoms Rare in pre-pubertal boys <11 yo

SYNCOPE

peak during adolescence 25% adults with have 1 episode in childhood low death Neurally mediated: Vasovagal Breath-holding in toddlers

Subacute Bacterial Endocarditis

prophylaxis tx in pts with CHD, valve replacements, previous endocartitis, etc Dental, Skin, MSK, and Respiratory Tract Procedures Dental Amoxacillin

T: Direct inguinal hernia

protrudes through center of triangle of Hesselbach; no obstruction More common in males Increased incidence in males

Clonic=

rapid contraction and relaxation of muscles (convulsions)

Who doesn't get Subacute Bacterial Endocarditis Prophylaxis treatment?

routine anethesia injection to noninfected tissue orhodontia shedding of deciduous teeth bleeding from trauma to lips or mucosa GI or GU tract procedures

Epilepsy

seizures are recurrent unrelated to fever and unprovoked

Automatism

set of brief, unconscious behaviors

Atonic=

sudden loss of tone (Drop Seizure_)

T: Childhood Absence Epilepsy

sudden profound impairment in consciousness w/o loss of body tone 10 sec duration Hi frequency 10+/day Onset: 4-10 20%+ have Hx febrile seizure 50% have 1st or 2nd degree relative w/seizures Increased General Tonic Seizure Syndrome Hi incidence of Psych cormorbs ADHD/anxiety

Tonic=

sudden tension of skeletal muscles

T: Inguinal hernia

the protrusion of a small loop of bowel through a weak place in the lower abdominal wall or groin

superficial inguinal canal

triangular opening that forms the exit of the inguinal canal, which houses the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the spermatic cord (in men) or the round ligament (in women)

Testicular self examination

using both hands to feel testis, roll testis between the thumb and first three fingers palpating each teste separately look in the mirror

T: Macroscopic hematuria

you can see it

CHEST PAIN PEARLS

• A good history (including FamHx) and physical looking out for any 'red flags' that could suggest a cardiac etiology is usually sufficient • Cardiac etiology of pediatric chest pain is rare (~ 1-5%) • Further testing is rarely indicated unless 'red flags' on history or physical are present • Reassurance is the most important thing you can do for the patient and the family

UA Dx

• Abnormal urinalysis and urine culture are Required forDx. • Children who are not toilet-trained must have a catheterized urine specimen • Toilet-trained children: a clean catch urine specimen can be obtained with the assistance of a parent or other adult • Bagged specimens are not useful unless negative. • Positive Leukocytes or nitrites with five or more WBC's and presence of bacteria on microscopy is highly predictive of infection • Urine culture for definitive diagnosis: 50,000 colonies per

Chest Pain Non-Cardiac

• Chest wall (1/3 of cases) - Non traumatic • COSTOCHONDRITIS (reproducible) • Precordial catch - Traumatic • Pulmonary - Asthma (EIA) - Pneumonia • GI - GERD: pain after eating or at night • Pshycogenic

T: When to get brain imaging in headaches

• Consistent HA upon awakening • HA awakens child from sleep • Thunderclap HA • Persistent nausea/vomiting • Altered mental status • Ataxia • Chronic progressive HA pattern • Change in quality, severity, frequency or pattern • Occipital HA • Recurrent localized HA • Lack of response to medical therapy

TEST Hematuria Lab in asymptomatic pt

• Initial urinalysis and urine culture • Further w/u is dependent on subjective/objective data • Repeat UA x2 every 2 weeks if asymptomatic • Referral: • Unclear cause of gross hematuria • Symptomatic microscopic hematuria • Persistent asymptomatic hematuria and proteinuria

Signs and Sx of Inreased ICP

•Abnormal exam •Headache •Recurrent or persistent nausea and vomiting •Cerebellar dysfunction •Cranial nerve palsy •Impaired vision •Abnormal eye movements •Papilledema •Seizures •Macrocephaly •Developmental delay •Behavioral changes •Endocrinopathies •Lethargy

T: When brain imaging is appropriate in Seizures

•Always if you suspect focal seizure •Always if their exam is abnormal •Always if high‐risk PMH - h/o neoplasm, stroke, coagulopathy, cardiac defect, ventricular shunt, sickle cell disease •Not needed if clearly benign epilepsy •Not needed after first unprovoked seizure

Febrile Seizure you must rule out

•CNS infection & underlying structural abnormality Altered level of consciousness Meningismus Petechiae Tense or bulging fontanelle Focal differences in muscle tone, strength, or movements • Post‐ictal drowsiness > 10 minutes

T: Febrile Seizure Risk Factors

•High fever •Viral infection •Recent immunization • DTP (6‐9/100,000) • MMR (25‐34/100,000) • MMR‐V (40/100,000) •FMH febrile seizures OTHER POSSIBLE RISK FACTORS •Prenatal exposure to nicotine •Iron insufficiency •Allergic rhinitis/atopic disease

When is brain imaging appropriate in HA and seizures?

•Plain radiographs (XR) • Non‐accidental trauma in infants • C‐spine trauma • Skull fracture •Computed tomography (CT) • Acute or emergent situations

T: Febrile Seizures

•Simple • Generalized • Duration <10‐15 min • No recurrence within 24 hours •Complex ANY OF THE FOLLOWING.... • Focal onset • Duration >15 minutes • Febrile status epilepticus - duration >30 minutes • >1 in 24 hours

T: When to investigate innocent murmur further

Any cardiac symptoms Murmur itself likely to be pathological Louder than 3/6 Loudest at apex Other cardiovascular abnormal signs - Cyanosis

Marfan Syndrome

Aortic Root Dissection Hyperflexible joints, arachnodactyly, aortic dissection, lens dislocation