Peds Combined

What are the first teeth to appear?

1. Lower central incisors 2. Upper central incisors

Turns head side to side Clenched fist Eye contact Recognizes human face Cries Startles at loud noise

0-2 months

expected urinary output in adult

0.5 mL/kg/hr

expected urinary output in child

1 mL/kg/hr

What time is Apgar score assessed

1, 5, and 10 minutes

Whole blood lead levels need to be obtained for lead poisoning. What lead blood is considered positive

10 or more

Mild thrombocytopenia

100,000 to 150,000 platelets

Prediabetes fasting glucose

100-125

Most patients are asymptomatic until serum calcium is greater than what?

12 mg/dL

Stands alone for 2 seconds Bangs two objects together Places pellet in bottle Hugs dolls or stuffed animals Routinely gestures to meet needs Uses one or two words with meaning

12-14 months

Prediabetes oral glucose tolerance test

140-199

Stoops and recovers Walks well Builds tower of two or three cubes Attempts use of spoon Waves bye-bye Uses four or five words

15-17 months

Runs well Kicks a large ball Walks backward Scribbles Turns pages of book Drinks well from a cup Feeds self Uses a spoon well Follows simple commands (e.g., give me) 20-50 words

18-21 months

Throws ball overhead Jumps Turns doorknobs Builds towers of six to seven blocks Washes and dries hands Little spilling during self-feeding Two or three words combined Points to body parts

2 years

When should you get the PCV13 for pneumonia

2, 4, 6 months, 1-1.5 years old

Lifts head Tracks object past midline Hands open Smiles responsively Vocalizes in play

2-3 months

which generation are the "respiratory" cephalosporins?

2nd generation

Stands on one foot at least 2 seconds Copies circle Takes turns Toilet trained Uses pronouns (I, me, you) Gives name

3 years

Hops on one foot Wiggles thumb Copies cross Dresses self Knows colors Asks questions

4 years

Head steady in supported position Hands together Shows displeasure through vocalization Looks for source of sound

4-5 months

Typically chelation therapy is only indicated if a patient has a blood lead level of what?

45 +

anti-flu drugs are only useful if taken within how long?

48 hours

Skips using alternate feet Holds a pencil correctly Brushes teeth without help Easily carries on a conversation May count or recite part of the alphabet

5 years

Prediabetes A1C

5.7-6.4

Teething generally occurs between _________ of age

6 to 24 months

The single most important prognosticator for a postoperative bariatric complication is what?

A persistent heart rate >120 bpm for more than 4 hours.

Formerly known as petit mal Brief impairment of consciousness with an abrupt beginning and ending. At times involuntary movements may occur, but they are uncommon and the patient has no recollection and witnesses commonly miss them

Absence Seizures

What suggests secondary polycythemia?

Absence of splenomegaly

Acetaminophen antidote

Acetylcysteine

Characterized by areas of open comedones (blackheads) incomplete blockage, closed comedones (whiteheads) complete blockage, papules, pustules, nodules or cysts. may result in scarring . I - Comedonal: comedones (+/- small amounts of papules and pustules) II - Papular: moderate number of lesions, little scarring III - Pustular: lesions > 25, moderate scarring IV - Nodulocystic: severe scarring

Acne Vulgaris

Treatment: 1st line: Topical retinoids. Cystic acne: tetracyclines, then oral retinoids, then isotretinoin Isotretinoin - SE: dry lips, liver damage, increased triglycerides/cholesterol, pregnancy category X - Must obtain 2 pregnancy tests prior to starting it and monthly while on it.

Acne Vulgaris

14-year-old boy with dozens of erythematous papules, pustules, and cysts. On closer exam, he also has atrophic scars on the lateral forehead, consistent with permanent scarring from previous acne lesions. He is started on topical retinoids and topical benzoyl peroxide. You suggest that he also consider a systemic retinoid if this topical therapy does not work.

Acne vulgaris

4-week old baby boy brought in by 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, papules on the lateral aspect of his face

Acne vulgaris

Antihistamines antidote

Activated charcoal Whole bowel irrigation Physostigmine

IgM

Acute

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

Clinical features: Rhinorrhea Sneezing Wheezing Low-grade fever Typically begins with URI prodrome which progresses with signs of lower respiratory distress including nasal flaring, tachypnea, and retractions

Acute Bronchiolitis

Inflammation of the bronchioles (airways smaller than 2 mm in diameter) MC in infants and young children <2 years MC Cause = RSV Other Causes - parainfluenza virus - adenovirus - rhinovirus Most infections occur during wintertime epidemics.

Acute Bronchiolitis

Management: Supportive care with primary goals of ensuring oxygenation and hydration If RSV is present: - consider hospitalization and administration of ribavirin - especially of high-risk patients such as infants born premature, those with underlying chronic conditions, or those who are severely ill Supportive measures - nebulized albuterol - intravenous (IV) fluids - antipyretics - chest physiotherapy - humidified oxygen

Acute Bronchiolitis

Auer Rods and > 20% blasts seen in bone marrow

Acute Myeloid Leukemia (AML)

Aur Rods and > 20% blasts seen in bone marrow

Acute Myeloid Leukemia (AML)

BLASTS + AUER RODS in ADULT PATIENT Population: - Adults (80%) - majority of patients > 50 y/o Anemia Thrombocytopenia Neutropenia Splenomegaly Gingival hyperplasia Leukostasis (WBC > 100,000)

Acute Myeloid Leukemia (AML)

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. The otoscopic exam is seen here

Acute Otitis Media

Clinical features Fever Ear pain (otalgia) Ear pressure Hearing impairment. Otoscopic examination may reveal tympanic membrane erythema and limited mobility with pneumotoscopy. Bulging and eventual rupture of the tympanic membrane can occur as well, leading to otorrhea and abruptly decreased pain.

Acute Otitis Media

Treatment: Watchful waiting may be adequate for older children without severe pain or fever. First line: Amoxicillin Allergy: Cephalosporin, TMP/SMX, azithromycin Recalcitrant or recurring cases, more invasive procedures such as tympanostomy, tympanocentesis, and myringotomy can be considered. Mastoiditis can occur with inadequate treatment

Acute Otitis Media

Viral URI that leads to eustachian tube dysfunction or blockage. A bacterial infection occurs with the subsequent buildup of fluid and mucus Less common causes include anatomic deformities or chronic edema. It is most common in infants and children, but any age group can be affected. Causes: - S. pneumoniae - H. influenzae - Moraxella catarrhalis - S. pyogenes.

Acute Otitis Media

-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 Phayngotonsillitis

9-year old girl is brought to the clinic by her mother on account of fever. She has red skin lesions on 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

Diagnostic Studies: Two major or one major and two minor Jones criteria are required for diagnosis Supportive evidence includes: - positive throat culture - rapid streptococci test - elevated or rising streptococcal antibody titer

Acute Rheumatic Fever

Systemic immune response occurring usually 2 to 3 weeks following a β-strep pharyngitis MC affects the heart, joints, skin, and central nervous system. MC in recent immigrant MC age 5-15 Valve diseas - may be self-limited - may lead to progressive deformity of the valve - typical lesion is a perivascular granuloma with vasculitis - MC in mitral valve followed by aortic

Acute Rheumatic Fever

Treatment: Strict bed rest is essential until the patient is stable. IM Penicillin for documented streptococcal infection (erythromycin is allergic) Salicylates reduce fever and relieve joint problems Corticosteroids relieve joint symptoms Prevention: - early treatment of streptococcal pharyngitis - benzathine penicillin every 4 weeks is a common prophylactic regimen

Acute Rheumatic Fever

HSV-1 MC in 6 months to 5 years of age. Acute symptoms last for 5 to 7 days Lesions heal in about 2 weeks, although shedding may continue Patients present with: - abrupt onset, fever, anorexia, listlessness, and gingivitis - Mucosa is red, swollen, and friable - Vesicles appear on the oral mucosa, tongue, and lips - these vesicles may rupture and coalesce to form ulcers and plaques - Regional lymphadenopathy is common.

Acute herpetic gingivostomatitis

This is common in adults manifesting initial HSV-1 disease and less common in those manifesting HSV-2 disease. Patients present: - fever, malaise, headache, and sore throat - Vesicles are formed on the posterior pharynx and tonsils - these vesicles rupture and form shallow ulcers - A grayish exudate may be present over the posterior mucosa.

Acute herpetic pharyngotonsillitis

CHILD Lymphadenopathy Bone pain Bleeding Fever Bone marrow > 20% blasts in bone marrow Population: - Children - most common childhood malignancy peak age 3-7 Highly responsive to chemotherapy (remission > 90%)

Acute lymphocytic leukemia (ALL)

Diagnosis: Terminal deoxynucleotidyl transferase

Acute lymphocytic leukemia (ALL)

Most common in children (3-7 years old)

Acute lymphocytic leukemia (ALL)

Characterized by maladaptive behavioral or emotional symptoms that develop within 3 months after an identifiable stressful life event and end within 6 months after the event. Stress-response syndrome Not due to bereavement or a life-threatening incident. Reaction is either out of proportion to the stressor or causes significant impairment in functioning. Symptoms include tearfulness, depressed mood, vandalism, reckless driving, truancy, fighting, and anxiety.

Adjustment disorder

Treatment: Supportive psychotherapy or group therapy. Short-term benzodiazepines, sleep aids, or SSRIs may be used for associated insomnia, anxiety, or depression but is not first-line treatment.

Adjustment disorder

Sensorineural hearing loss on Rinne Test

Air conduction > Bone conduction on affected side (normal finding this test)

Liver enzymes: AST:ALT ratio > 2:1

Alcoholic Hepatitis

Elevated when the bone is broken down and remodeled

Alkaline phosphatase Lactate dehydrogenase

Clinical Features: Red eyes Itching and tearing Usually bilateral Cobblestone mucosa on the inner/upper eyelid

Allergic Conjunctivitis

Treatment: Systemic antihistamines and topical antihistamines or mast cell stabilizers. - Epinastine - Azelastine - Emedastine difumarate - Levocabastine

Allergic Conjunctivitis

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

Clinical features: Symptoms may be confused with those of a common cold. Allergic shiners Allergic salute Rhinorrhea Itchy or watery eyes Sneezing Nasal congestion Dry cough Pale, boggy, or bluish mucosa The discharge usually is clear and watery.

Allergic Rhinitis

Refers to any inflammation of the nasal mucosa. Immunoglobulin E (IgE)-mediated reactivity to airborne antigens (e.g., pollen, molds, danders, dust). It commonly occurs in people who have other atopic diseases (e.g., asthma, eczema, atopic dermatitis) and those with a family history.

Allergic Rhinitis

Treatment Avoid any known allergens Antihistamines Cromolyn sodium Nasal or systemic corticosteroids Nasal saline drops or washes Immunotherapy

Allergic Rhinitis

Delays intestinal glucose absorption

Alpha-glucosidase inhibitors

Delays intestinal glucose absorption SE: GI

Alpha-glucosidase inhibitors

what 2 drugs are used only for influenza A prophylaxis and treatment?

Amantadine and Rimantadine

Reduced visual acuity not correctable by refractive means Causes: - strabismus (most commonly) - uremia - toxins, such as alcohol, tobacco, lead, and other toxic substances.

Amblyopia

Ototoxic drugs

Aminoglycosides (gentamycin, tobramycin) Loop diuretics (furosemide) Anticancer drugs (cisplatin)

What is the maculopapular rash of mononucleosis treated with?

Ampicillin

Neonates up to 1 month with bacterial meningitis tx

Ampicillin Cefotaxime Gentamicin

Adults older than 50 years of age and those of any age with alcoholism or debilitating illness with bacterial meningitis tx

Ampicillin + cefotaxime OR Ceftriaxone + vancomycin

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

Can manifest as hyperactivity and impulsivity or as inattentiveness Most children manifest symptoms that result in a diagnosis emphasizing both attention deficits and hyperactivity Secondary symptoms include: - emotional immaturity and lability - poor social skills - sometimes, motor incoordination Disruptive behavior may result in peer rejection and deflated self-image. At home, these children often do not comply with parents' requests and can become explosive and irritable.

ADHD

Diagnosis: Interviews, observations, and questionnaires with parents and teachers in combination with rating scales Diagnostic criteria - Symptoms of hyperactivity, impulsivity, or inattentiveness resulting in impairment must have been present before 12 years of age. - Symptoms must occur in at least two settings (e.g., home, school) - At least six symptoms of inattention, hyperactivity/impulsivity, or both, are developmentally inappropriate and present for at least 6 months.

ADHD

Treatment: CNS stimulants in combination with behavioral therapies, social skills training, and school-based interventions Stimulants - methylphenidate - dexmethylphenidate - amphetamine/dextroamphetamine - Side effects = growth retardation, weight loss, labile mood, tics, and insomnia Atomoxetine - selective norepinephrine reuptake inhibitor (non-stimulant) - Efficacy is equal to that of the stimulants - Side effects are similar but less frequent

ADHD

Treatment Appendectomy If abscess or perforation: broad spectrum antibiotics are administered before and after surgery

Appendicitis

Breast Tanner Staging 4

Areola forms secondary mound

The American Dental Association and the American Academy of Pediatric Dentistry recommend scheduling a child's first dental visit when?

At or near first birthday

Also known as drop attacks Looks like syncope, sudden loss of muscle tone

Atonic Seizures

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 the antecubital fossa, wrist, hands, ankle & feet.

Atopic Dermatitis (Eczema)

Pruritic, eczematous lesions Xerosis (dry skin) Lichenification (thickening of the skin and an increase in skin markings) MC on flexor creases (ex. antecubital and popliteal folds) Infant- face, and scalp Adolescent- flexural surfaces IgE, type 1 hypersensitivity

Atopic Dermatitis (Eczema)

Treatment: Antihistamines help to control pruritus and itching. Topical corticosteroids are the mainstay of the treatment Tacrolimus and pimecrolimus approved for moderate to severe cases Hydration and topical emollients are key to management Ultraviolet B (UVB) phototherapy is effective.

Atopic Dermatitis (Eczema)

Strongest predisposing factor to asthma

Atopy

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. An echocardiogram

Atrial Septal Defect

Diagnosis: - Passing a catheter through defect Treatment: - Symptomatic: Diuretics, ACE inhibitors, digoxin - Definitive: Surgical closure

Atrial Septal Defect

Opening between the right and left atria. Of the four main types, ostium secundum is the most common. Noncyanotic Defects

Atrial Septal Defect

Second most common congenital heart disease Systolic ejection murmur at 2nd LICS Early to middle systolic rumble Failure to thrive Fatigability RV heave Wide fixed split S2

Atrial Septal Defect

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

Children usually lack constitutional symptoms Present in 95% of cases with unilateral, subacute, progressive lymphadenopathy The swelling is painless, firm and not erythematous MC in 1-5 year olds

Atypical Mycobacterial Disease

Treatment: Tetracyclines (-cycline) Fluoroquinolones (-floxacin) Macrolides (erythromycin, azithromycin, clarithromycin) Sulfonamides (sulfa-) For 4-6 weeks.

Atypical Mycobacterial Disease

Hearing is best assessed during the newborn period by what?

Auditory brain stem response (ABR) or Evoked otoacoustic emission testing (OAE)

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

Characterized by: - impaired social interaction - impaired communication - repetitive stereotyped patterns of behavior and activitie Apparent by age 3 to 6 months These children are often aloof, withdrawn, and lack facial expression Parents are usually the first to note that the child does not respond to cuddling or has not developed a normal pattern of bonding or smiling.

Autism Spectrum Disorder

Diagnosis: Lack of reciprocal social interaction Fail to develop language skills Do not progress through expected developmental milestones Absence of spontaneous and varied play activities is prominent. Restricted repertoire of interests Intense adherence to specific routines Hyper or hypo sensory responses Repeated motor movements or mannerisms that are not goal directed

Autism Spectrum Disorder

Treatment: Multidisciplinary supportive care. Behavioral therapy - most effective - specialists and speech and language pathologists should be consulted - audiology evaluation and EEG may be indicated as well Pharmacotherapy to reduce impulsivity and irritability - second-generation antipsychotics (e.g., risperidone, aripiprazole) - conventional antipsychotics (e.g., haloperidol) - neuroleptics (e.g., carbamazepine) SSRIs can help control repetitive behaviors but may cause increased agitation or mania.

Autism Spectrum Disorder

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 Proximal Femur

AKA Aseptic necrosis of hip AKA osteonecrosis of hip

Avascular Necrosis of the Proximal Femur

Clinical features: Dull ache or throbbing pain localized to the groin, lateral hip, or buttocks. Pain with weight-bearing and activity that is relieved with rest Loss of rotation (internal and external) or abduction Sntalgic limp are observed. Children - persistent pain - a limp, - loss of motion, particularly internal rotation and abduction Adverse outcomes: - secondary OA, femoral head collapse, and disability

Avascular Necrosis of the Proximal Femur

Imaging: MRI is the study of choice for early detection. Radiography - normal early in the course of adult disease - later reveals a crescent sign in lateral films Radiography in children - show soft-tissue swelling - joint distension - increased bone density - fragmentation - deformed femoral head

Avascular Necrosis of the Proximal Femur

Results from loss of blood supply to the trabecular bone which causes a collapse of the femoral head Often bilateral. In children - Legg-Calvé-Perthes (LCP) disease - 2-11 y.o. Cause is generally unknown, but it is often seen in patients with a history of trauma, steroid use, alcohol abuse, RA, radiation therapy, and SLE.

Avascular Necrosis of the Proximal Femur

Treatment Protected weight-bearing for early stage disease is considered to be a temporary treatment Alendronate has been used to prevent early collapse. Surgical options range from core decompression to total hip replacement. In children - protected weight-bearing - little benefit has been shown from bracing.

Avascular Necrosis of the Proximal Femur

Chronic Hepatitis Transmitted parenterally or by mucous membrane contact

B C D

Diagnostic Studies: Microscopic examination of cut or plucked hair fibers and scalp biopsies may provide additional information that is helpful for diagnosis - Biopsy: telogen and atrophic follicles - Trichogramma: increased telogen hairs Hormones: testosterone, DHEA, Prolactin Treatable: thyroid (TSH), anemia (CBC), autoimmune (ANA)

Androgenetic Alopecia

Gradual conversion of terminal hairs → Indeterminate → Vellus hair Genetic predisposition (androgen) M 20-40yo W: MC after 50 Men > Women (MC in white men)

Androgenetic Alopecia

Treatment: Topical: Minoxidil/Rogaine; hair loss first before regrowth Finasteride 1mg ⇒ inhibits T and DHT Spironolactone ⇒ blocks DHT

Androgenetic Alopecia

Microcytic/Normocytic Anemia ↓ Iron ↓ TIBC 10-20% Saturation ↑ Ferritin Normal Hemoglobin Normal Indirect bilirubin LDH Elevated CRP/ESR

Anemia of Chronic Disease

Painless, deeper form of urticaria affecting the lips, tongue, eyelids hand and genital

Angioedema

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.

Anorexia Nervosa

Patients have a distorted body image and an intense fear of becoming fat, even though they are underweight. Patients deny the seriousness of their low body weight. Patients may exercise excessively, and they commonly have food-related obsessions (e.g., hoarding food, collecting recipes). Peak onset is during early adolescence

Anorexia Nervosa

Signs and symptoms: Emaciation Orthostatic hypotension Bradycardia Hypothermia Dry skin Lanugo Peripheral edema Amenorrhea/delayed menarche Salivary gland hypertrophy Dental erosion/loss of tooth enamel Calluses or abrasions on the back of the hand from induced vomiting Constipation Leukopenia Electrolyte abnormalities (hypochloremia, hypokalemia, elevated BUN, metabolic alkalosis) Arrhythmias

Anorexia Nervosa

Treatment: Family members usually are first to bring this disorder to attention A multidisciplinary approach to treatment is essential. 1. Restore the patient's nutritional state. - Hospitalization often is indicated, especially if the patient is more than 20% below the expected body weight. 2. Outpatient management consists of behavioral therapy, family therapy, and supervised weight gain programs. This can be initiated by adding 500 calories more than the amount needed to maintain present weight and then increasing gradually by spreading feedings to 6/day. Certain antidepressants (amitriptyline, paroxetine, mirtazapine) can be used, especially when depression is present. - medications do not play a major role in the treatment of this disorder.

Anorexia Nervosa

Two types: - restricting - binge eating and purging BMI - >17 kg/m2 is mild - 16 to 16.99 is moderate - 15 to 15.99 is severe - <15 is extreme.

Anorexia Nervosa

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

Better heard if leaning forward and aortic valve

Aortic stenosis

Crescendo decrescendo systolic ejection murmur

Aortic stenosis

Radiates to carotids

Aortic stenosis

Diagnostic studies: bone marrow biopsy Treatment: - stop causative agent - RBC transfusion - bone marrow transplant - immunosuppressive agents

Aplastic Anemia

The only anemia where all three cell lines are decreased (pancytopenia) - ↓ WBC - ↓ RBC - ↓ Platelets - will have normal MCV and ↓ Retic Loss of blood cell precursors Causes: chemicals, drugs, radiation (ACE-I, sulfonamides, phenytoin, chemo, radiation)

Aplastic Anemia

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

Clinical Features: Initially: - intermittent periumbilical or epigastric pain 12 hours - localizes to RLQ (McBurney point) - worsened by movement - rebound tenderness Psoas sign Obturator Sign Rosving sign (palpate LLQ, felt in RLQ)

Appendicitis

Diagnosis: Leukocytosis (10,000-20,000) Microscopic hematuria and pyuria Abdominal US (preferred imaging) CT (most sensitive)

Appendicitis

Occurs when obstruction of the appendix leads to inflammation and infection Causes - fecalith MC - infection - collagen vascular disease - inflammatory bowel disease Perforation and peritonitis occur in about 20% of patients (causes fever, ab pain, leukocytosis)

Appendicitis

Employ binge eating as well as vomiting, use of laxatives and/or diuretics, excessive exercise, or other measures to avoid gaining weight These maladaptive behaviors occur at least 1 day/week for 3 months. Commonly maintain a normal body weight, or they may even be overweight - Rapid fluctuations in weight Patients with bulimia tend to be high achievers and respond to societal pressure to be thin

Bulimia Nervosa

Mild: 1 to 3 episodes/week Moderate: 4 to 7 episodes/week Severe: 8 to 13 episodes/week Extreme: ≥14

Bulimia Nervosa

Physical findings: Dental erosion Esophagitis Callused or abraded knuckles Hypochloremic Hypokalemic metabolic alkalosis Hypomagnesemia Hypocalcemia Salivary gland hypertrophy Cardiac arrhythmias Elevated amylase Gastric distention.

Bulimia Nervosa

Treatment: Restoring the patient's nutritional state is the first treatment. Antidepressants, such as SSRIs (fluoxetine) Behavioral psychotherapy should be used in conjunction with family therapy. Hospitalization usually is not necessary - exceptions are the presence of suicidal ideation or significant metabolic or electrolyte disturbances due to severe purging.

Bulimia Nervosa

What is contraindicated in anorexia and bulimia?

Buproprion (lowers seizure threshold in pts with electrolyte abnormalities)

Treatment: Stop burning process - sterile water (make sure there are no powders on individual if dealing with chemical substance) Manage shock with aggressive fluid resuscitation with LR - Parkland Formula - Colloids can be introduced during second 24 hours Monitor urine output (foley catheter) Insert NG tube

Burns

Health care providers are required to alert the appropriate authorities if suspected. When a young patient presents with any condition that appears questionable for physical, emotional, or sexual abuse or neglect, it is best to consult with a mental health professional or family social services. The child must be protected from further abuse as well as treated for current injuries.

Child Abuse

Physical signs: Any injury that cannot be adequately explained or is not consistent with the history given has the potential of being abuse. Bruises, lacerations, soft-tissue swelling, dislocations, or fractures and spiral fractures are common. Burns that are doughnut shaped, in a stocking-glove distribution, or symmetrically round (e.g., caused by a lit cigarette) Bruises or injuries that form regular patterns on the face, back, buttocks, or thighs Other physical signs are internal hemorrhages, abdominal injuries, bite marks, and injuries that have the shape of the instrument used to make them (e.g., belt, cord, hand).

Child Abuse

Psychiatric disturbances as a result are common Can be manifested in subtle ways, such as failure to thrive. Corporal punishment within reason is not normally considered to be abuse; it becomes abuse if the parent indicates receiving gratification while administering the punishment.

Child Abuse

When an adult allows a minor to engage in potentially harmful behavior (e.g., alcohol consumption) or remain unattended. In some states, leaving a child younger than 13 years of age at home alone is indicative.

Child Neglect

Longer prodrome Sore throat, hoarseness What kind of pneumonia?

Chlamydia pneumoniae

May be normal or seen in infants with osteogenesis imperfecta

Blue or cyanotic sclera

Conductive hearing loss on Rinne Test

Bone conduction > Air conduction on affected side

Well-demarcated erythema, erosions, vesicles Allergic: Nickel, poison ivy, etc. Type 4 hypersensitivity Irritant (diaper rash): Cleaners, solvents, detergents, urine, feces

Contact Dermatitis

Diagnostic studies: Direct visualization of the epiglottis is diagnostic, but manipulation may initiate sudden, fatal airway obstruction in children. This is less common in adults. Once the airway is secured, obtain a CBC and blood and epiglottic cultures. A lateral neck radiograph shows a swollen epiglottis (thumbprint sign)

Epiglottitis

Management: Secure airway: Do not move or upset the child unless prepared to manage the airway. Administer broad-spectrum second- or third-generation cephalosporin such as cefotaxime or ceftriaxone for 7 to 10 days. Dexamethasone may also be indicated to reduce inflammation.

Epiglottitis

This is a severe, life-threatening infection of the epiglottis MC between 2-7 y.o. The widespread administration of the H. influenzae type B (Hib) vaccine has decreased the incidence MC etiologies in adults include: - group A Streptococcus - S. pneumoniae - H. parainfluenzae - S. aureus.

Epiglottitis

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

Anaphylactic reaction to previous - Bakers yeast = no Hep B - Eggs = influenza - gelatin = varicella Encephalopathy w/in 7 days no DTaP Pregnancy = no live

Contraindications to Vaccine

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

Epistaxis

Risk factors: Nasal trauma (i.e., nose picking) Dry nasal mucosa Hypertension Nasal cocaine Alcohol use

Epistaxis

Small, pearly nodules along the midline of the hard palate and are benign retention cysts

Epstein Pearls

4-year-old who is brought to the office by his mother. The child has had a low-grade fever, headache, and sore throat for the past week. Four days ago, he suddenly developed a bright red rash on his cheeks, which during the past two days has spread to the trunk, arms, and legs. On physical examination, the child has erythema of the cheeks and a maculopapular rash with central clearing on the trunk spreading to the extremities. There are no other significant findings.

Erythema Infectiosum

AKA Fifth Disease AKA Slapped Cheek

Erythema Infectiosum

Etiology: Human parvovirus B19 Incubation Period: 4-14 days Prodrome: None Rash: Red face ("slapped cheek"); lacy, pink, macular rash on torso

Erythema Infectiosum

Acute, self-limited, and sometimes recurring skin condition Type IV hypersensitivity reaction Associated with - MC HSV (90%) - medication (sulfa drugs) Skin lesions predominantly involving the extremities (hands, feet, and mucosa). Target-like shape, raised, blanching, and lack of itchiness help characterize this rash.

Erythema Multiforme

DX: Clinical hx and PE Raised (papular), target lesions with multiple rings and dusky center (as opposed to annular lesions in urticaria) Negative Nikolsky sign (as opposed to SJS/TEN)

Erythema Multiforme

Treatment: Remove the offending agent Mucocutaneous lesions - IV fluids if needed - oral compound solution - systemic steroids for severe (Prednisone 40-60mg) Ocular: immediate referral/consult Recurrent: antiviral QD

Erythema Multiforme

Parvovirus B19 "Slapped cheek" rash on face Lacy reticular rash on extremities Spares palms and soles Resolves in 2-3 weeks Treatment is supportive, anti-inflammatories

Erythema infectiosum

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

Common; first appears 3 to 5 days after birth as small pustules on erythematous bases (halos). Normally, the rash spreads centripetally and spontaneously; resolves within 1 to 2 weeks.

Erythema toxicum

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 and nitrites.

Cystitis

Clinical features: Irritative voiding symptoms (frequency, urgency, dysuria) Suprapubic discomfort. Gross hematuria may occur Symptoms in women often appear following sexual intercourse or use of a diaphragm with spermicide

Cystitis

Diagnostic studies: Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria. Urine culture is positive (>103 CFUs/mL) for the offending organism Imaging is warranted only if pyelonephritis, recurrent infections, or anatomic abnormalities are suspected.

Cystitis

Infection of the normal bladder The route of infection typically is ascending from the urethra. MC caused by e. coli (occasionally enterococci) MC in women.

Cystitis

Treatment: Uncomplicated cystitis in women can be treated with short-term antimicrobial therapy. Uncomplicated cystitis is rare in men. Fluids should be encouraged. Hot sitz baths or urinary analgesics (phenazopyridine) may provide symptomatic relief. Patients should be warned that phenazopyridine will discolor the urine dark orange or reddish. Preventive measures - proper hygiene - urine acidification - voiding after intercourse.

Cystitis

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

Significant depletion of body water and, to varying degrees, electrolytes Mild (3-5%) Moderate (6-9%) Severe (≥10%) In children moderate or severe: - prolonged capillary refill - poor skin turgor - abnormal breathing - sunken eyes - decreased activity - a lack of tears - a dry mouth A normal urinary output and oral fluid intake is reassuring

Dehydration

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 Disorder

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.

Diabetes Mellitus

Autoimmune- HLA-DR3/4/O antibodies. Islet cell antibodies MC in Children Risk of DKA

Diabetes Mellitus Type 1

Clinical Features: Polyuria Polydipsia Polyphagia Fatigue Weight loss Dawn Phenomenon Somogyi effect

Diabetes Mellitus Type 1

Low Insulin and C peptide levels GAD65 IA-2 antibodies

Diabetes Mellitus Type 1

Treatment: Insulin

Diabetes Mellitus Type 1

High fasting insulin and C peptide

Diabetes Mellitus Type 2

Treatment: Metformin Sulfonylureas Thiazolidinedione Alpha-glucosidase inhibitors Meglitinides GLP-1 Agonist DDP 4 inhibitors SGLT2 inhibitors Insulin if A1c > 9

Diabetes Mellitus Type 2

Labs - elevated glucose > 250 - low bicarb - low pH - ketonuria

Diabetic Ketoacidosis

Symptoms: - Fruity breath - nausea, vomiting - dehydration - tachypnea (Kussmaul breathing)

Diabetic Ketoacidosis

Treatment: - treated in the ICU - IV regular insulin - large volumes of fluids

Diabetic Ketoacidosis

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.

Diaper Dermatitis

Diagnosis: Laboratory tests are not necessary but may help confirm the diagnosis in recalcitrant cases KOH prep and fungal culture of skin scrapings for Candida Viral culture, mineral oil slide for scabies Culture of skin lesions for S. aureus or group A Streptococcus

Diaper Dermatitis

Make sure to do a good oral exam as children with a this rash often have concurrent thrush. Another good question is to ask a breastfeeding mother if she has burning or redness on her breasts which can also be transmitted between the infant and the mom.

Diaper Dermatitis

Rash on buttocks region, common in infants 3wk ⇒ 2 yrs. Fussiness Crying w/ diaper change Diarrhea Shiny erythema with dull margins Cause: wet, dark, friction, urine, feces, and microorganisms Secondary infections - Satellite lesions ⇒ candidiasis - Impetigo (s. aureus) - Herpes simplex virus (child sexual abuse)

Diaper Dermatitis

Treatment: Keep area dry to allow airflow Barrier creams zinc oxide/petroleum jelly Candidiasis: - Nystatin, Clotrimazole, Econazole x 2 wks. Discuss proper diaper changes, disposable, avoid tight-fitting

Diaper Dermatitis

Severely scaphoid belly plus respiratory distress suggests what?

Diaphragmatic Hernia

Meds agents used for lead toxicity

Dimercaprol CaNaEDTA Penicillamine Succimer

Passage of intestine through the external inguinal ring at Hesselbach triangle Rarely enters the scrotum What kind of hernia?

Direct Inguinal Hernia

Any age Cause: sepsis, burns, trauma Abnormal PT/PTT Bleeding and clotting disorder Treatment: - fresh frozen plasma - Cryoprecipitate - Platelets

Disseminated Intravascular Coagulation (DIC)

As a child aged 2 years or younger with weight plotting below the fifth percentile for age on more than one occasion or whose weight crosses two major percentiles downward on a standardized growth grid

Failure to thrive

Clinical features: Patients with episodic hemolysis are usually healthy and have no splenomegaly. Female carriers are rarely affected.

G6PD Deficiency

Laboratory findings: During hemolytic episodes - reticulocytes increase - serum indirect bilirubin increase. Peripheral smear reveals - bite cells - Heinz bodies (denatured hemoglobin).

G6PD Deficiency

Treatment: In most cases, hemolytic episodes are self-limited as red cells are replaced as soon as the offending agent is stopped Oxidative drugs and fava beans should be avoided.

G6PD Deficiency

X-linked recessive disorder MC - American black males (10% to 15%) - some Mediterranean populations Episodic hemolysis causes: - Oxidative drugs (e.g., aspirin, dapsone, primaquine, quinidine, sulfonamides, nitrofurantoin) - fava bean ingestion - infection cause episodic hemolysis Severe deficiency may cause chronic hemolysis.

G6PD Deficiency

Exanitide Dulaglutide Semaglutide (Ozempic) Liraglutide

GLP-1 Agonists

Mimics incretin - causes insulin secretion and decreased glucagon SE: requires injection, GI Benefits: weight loss, reduced CV mortality

GLP-1 Agonists

Neonatal nausea and vomiting, jaundice, hepatic dysfunction and liver enlargement, intellectual disability, cataracts, and death Dx: Galactose-1-phosphate uridyltransferase electrophoresis after galactose intake Tx: Lactose- and galactose-free diet

Galactosemia

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

Most common form of Salmonella infection. 8 to 48 hours after ingestion of contaminated food or drink. Fever, nausea and vomiting, crampy abdominal pain, and bloody diarrhea last 3 to 5 days. Diagnosis is made through stool culture.

Gastroenteritis

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.

Gastroesophageal Reflux Disease

Clinical features: MC Heartburn - worse after meals and when lying down - relieved with antacids Hoarseness Halitosis Sore throat More severe disease, generally caused by a severe impairment of lower esophageal sphincter tone, occurs spontaneously when supine, whereas less severe disease is associated with a pattern of heartburn following meals but not associated with nighttime symptoms.

Gastroesophageal Reflux Disease

Diagnostic studies Most often, a clinical diagnosis More severe symptoms warrant endoscopy to confirm the diagnosis and to assess for epithelial damage. Be sure to consider the possibility that symptoms are caused by myocardial ischemia (ECG) Severe or refractory cases - Barium swallow - Esophageal manometry - Ambulatory 24-hour pH monitoring Consider CBC to evaluate for anemia if there is suspicion of esophageal bleed.

Gastroesophageal Reflux Disease

Result of recurrent reflux of gastric contents into the distal esophagus because abnormality of the lower esophageal sphincter. Can lead to Barrett esophagitis Medications may cause or worsen: - including antibiotics (tetracycline) - bisphosphonates - iron - NSAIDs Other predisposing factors include: - obesity - pregnancy - diabetes - hiatal hernia

Gastroesophageal Reflux Disease

Treatment Lifestyle modifications - Smoking cessation - No eating before bedtime - Avoid large meals - Avoidance of alcohol, caffeine, etc - Raise the head of the bed Pharmacotherapy - Antacids if mild - Histamine (H2) blockers (cimetidine, ranitidine, famotidine, nizatidine) - PPI (-prazole) is first line in moderate to severe disease or in patients who are unresponsive to H2 blockers or have evidence of erosive gastritis. Surgical and endoscopic techniques are available for refractory cases

Gastroesophageal Reflux Disease

Hemolysis Elevated Liver enzymes Low Platelets Population: Pregnant females Cause: Eclampsia Treatment: Delivery, MgSO4

HELLP Syndrome

Varicella

HHV 3

EBV

HHV 4

CMV

HHV 5

MC cause of erythema multiforme

HSV

Has a predilection for the trigeminal nerve More than 85% of the U.S. population has evidence of infection with this type of HSV Transmission is via infected saliva. Primary infection can be asymptomatic or produce severe disease. Recurrent, self-limited attacks are common.

HSV Type 1

Has a predilection for the sacral root ganglion About 25% of the U.S. population is infected with this type of HSV. Transmission is via sexual contact or from the mother's genital tract during delivery. Typically causes genital lesions (vulva, vagina, cervix, glans, prepuce, and penile shaft) Asymptomatic shedding and painful eruptions can be frequent.

HSV Type 2

Chronic Asymptomatic Transmission: IV drug use is the most common. Also sexual or sanguineous Screen with testing for anti-HCV antibodies Diagnosis with HCV RNA quantitation Risk of cirrhosis and hepatocellular carcinoma Treatment: antiretrovirals target complex of enzymes needed for HCV RNA synthesis Hepatitis C

Hepatitis C

Only occurs when coinfected with Hepatitis B Risk of hepatocellular carcinoma

Hepatitis D

Pregnant woman, 3rd world countries This + mother = high infant mortality Treatment: Supportive. Vaccinate against other viral hepatitis. HIV treatment PRN.

Hepatitis E

empty sella syndrome

Herniation of arachnoid & CSF into the sella compresses & destroys pituitary gland Pituitary gland is "absent" on imaging

Roseola (sixth disease) cause

Herpes 6 or 7

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

Diagnostic studies: Usually established clinically. Vesicular fluid may be cultured (definitive) or stained (Tzanck smear, immunofluorescent staining) revealing multinucleated giant cells. Antibodies can be identified in the serum by PCR techniques.

Herpes Simplex

Humans are the only reservoir Transmission is via close contact and inoculation of virus into the mucosal surface or through cracks in the skin. Reactivation may be precipitated by fever, stress, menses, trauma, ultraviolet light, weight gain or loss, immunosuppression, or other factors. Reactivation is more frequent and more severer in patients who are immunocompromised.

Herpes Simplex

Treatment: Local wound care and supportive therapy are recommended. Treatment is with antivirals (e.g., acyclovir, valacyclovir) Patients with frequent outbreaks may benefit from suppressive therapy. Foscarnet is beneficial in immunocompromised patients with resistant infections. Keratitis is treated with trifluridine.

Herpes Simplex

All warts are caused by the ______________

Human Papillomavirus (HPV)

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

Clinical features: - Infant will demonstrate typical signs of respiratory distress. Diagnostic studies: - CXR demonstrates air bronchograms - Diffuse bilateral atelectasis causing a ground-glass appearance - Doming of the diaphragm.

Hyaline Membrane Disease

Most common cause of respiratory disease in the preterm infant It is caused by a deficiency of surfactant.

Hyaline Membrane Disease

Now called respiratory distress syndrome; RDS

Hyaline Membrane Disease

Treatment: Synchronized intermittent mandatory ventilation should be used. Administration of exogenous surfactants can be used in the delivery room as prophylaxis or as rescue if established

Hyaline Membrane Disease

ECG - Left ventricular hypertrophy - Exaggerated septal Q waves Echo - Left ventricular hypertrophy - Asymmetric septal hypertrophy - Small left ventricular size - Normal or supranormal function

Hypertrophic Cardiomyopathy

This cardiomyopathy demonstrates: - massive hypertrophy (particularly of the septum) - small left ventricle - systolic anterior mitral motion - diastolic dysfunction MC in Asian descent Sudden cardiac death occurs in patients younger than 30 years of age at a rate of 2% to 3% yearly

Hypertrophic Cardiomyopathy

Treatment: Initial treatment: - β-blockers or CCB - Disopyramide is used for its negative inotropic effects. Surgical or nonsurgical ablation of the hypertrophic septum may be required Maybe - Dual-chamber pacing - Implantable defibrillators - Mitral valve replacement

Hypertrophic Cardiomyopathy

Acute - self-limited - autoimmune (IgG) disorder - MC in children - preceding viral URI - Tx: resolves spontaneously Chronic - any age - MC in women - coexists with HIV, Hep C, Autoimmune diseases

Idiopathic thrombocytopenic purpura (ITP)

Most Common Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum Often congenital and will present before age one Remember: goes through the Internal Inguinal Ring (an "I" for an "I") What kind of hernia?

Indirect Inguinal Hernia

Aspirin (salicylates) antidote

Induce emesis Charcoal to bind drug Correct dehydration Hemodialysis

Congenital causes include: - asphyxia - erythroblastosis - maternal rubella Acquired causes: - measles - mumps - pertussis - meningitis - influenza Clinical features include inattentiveness to human voices or lack of reaction to noise

Infancy and childhood hearing loss

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

AKA Trisomy 21

Down Syndrome

Common characteristics Associated with advanced maternal age. Hypotonia Poor Moro reflex Hypermobility of joints Flattened facies and occiput Excess skin on the posterior neck Anomalous auricles Upward-slanting palpebral fissures Pelvic dysplasia, dysplasia of the middle phalanx of the fifth finger Single transverse palmar crease (simian crease) Congenital heart disease is present in up to 40% of cases; atrioventricular septal defects are most common.

Down Syndrome

Diagnosis: Ultrasound Prenatal diagnosis ⇒ Nuchal translucency (weeks 11-14) - Increased nuchal translucency and a hypoplastic nasal bone in a first-trimester ultrasound Lab results ⇒ Prenatal diagnosis - Chorionic villus sampling - Amniocentesis

Down Syndrome

Most common issues: Septal defects between atria Duodenal atresia Increased risk for acute lymphoblastic leukemia Mental retardation and an increased risk for Alzheimer disease Sterility in males

Down Syndrome

↑ serum β-hCG, inhibin A ↓ unconjugated estriol (uE3) ↓ Alpha-fetoprotein (AFP)

Down Syndrome

what is the DOC for tick-borne diseases in children over 8 y/o?

Doxycycline

An adverse cutaneous reaction in response to the administration of a drug. Skin reactions are the most common adverse drug reactions. Severity can range from mild eruptions that resolve after the removal of the inciting agent to severe skin damage with multiorgan involvement

Drug Eruptions

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

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

Congenital absence or complete closure of a portion of the lumen of the duodenum Causes: - increased levels of amniotic fluid during pregnancy (polyhydramnios) - intestinal obstruction in newborn babies Increased association with Down's syndrome

Duodenal Atresia

Diagnosis: Commonly made prenatally, either as an isolated lesion or due to its association with other chromosomal abnormalities X-ray: double bubble Malrotation: corkscrew

Duodenal Atresia

Treatment: Suction/Drain secretions Respiratory Elevate head IV glucose and fluid Antibiotics Definitive: SURGERY

Duodenal Atresia

Laron syndrome

Dwarfism that results from a mutation in the GH receptor.

Treatment: Parent education and reassurance Assure them their baby is healthy & crying can increase and likely stop by ~ 3-4mo Assure them they are not to blame Make sure the baby is not hungry, soiled, or tired Swaddle, gentle motions, pacifier Get help from family to get a break! Possible formula switch or GERD tx

Colic

Patients older than 50 years of age with new-onset constipation should be evaluated for what?

Colon Cancer

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

Clinical Presentation: Legs of unequal lengths Asymmetric skin folds around the groin May develop limping and waddling gait when they start walking

Congenital Hip Dysplasia

Diagnosis: Based on physical exam ⇒ hip exam at every well-child visit until age 2 Barlow maneuver Ultrasound can be used to assess the position of the femoral head and the structure of the acetabulum Radiographs are unreliable until the patient is at least four months old because of radiolucency of femoral head

Congenital Hip Dysplasia

Socket or acetabulum and the femoral head are misaligned Results in an unstable hip joint Typically, the problem is present at birth, but sometimes it appears later as the bones develop over time

Congenital Hip Dysplasia

Treatment: Below six months - Pavlik harness and closed or open reduction for older kids, and in some cases, surgery might be necessary < 6 months old: Pavlik harness (abduction bracing) 6-15 months old: hip spica cast 15-24 months old: open reduction followed by hip spica cast

Congenital Hip Dysplasia

Virilized female; males may have ambiguous genitalia; infants may present early in life with salt-wasting, adrenal crisis Dx: 17-Hydroxyprogesterone Tx: Corticosteroid replacement

Congenital adrenal hyperplasia

6-year-old boy complaining of itchy eyes. The mother states that she has noted that he has been tearing 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 of both eyes.

Conjunctivitis

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 accidents despite successfully potty training over a year ago.

Constipation

Decrease in stool volume and an increase in stool firmness accompanied by straining

Constipation

Treatment: Increase in insoluble fiber (up to 10 to 20 g/day) Increased fluid intake (up to 1.5 to 2 L/day) Increased exercise Lasting for more than 2 weeks should undergo further investigation to detect the underlying cause Mineral oil Polyethylene glycol Lactulose

Constipation

Selected testing: Further testing is driven by the history and physical examination findings Testing is done to rule out other causes as mentioned in failure to thrive. Radiography of the distal radius reveals chronological age greater than bone age. Treatment: Growth is delayed, but eventually the child will reach his or her expected height.

Constitutional growth delay

The child is often called a "late bloomer" and may have a family history of delayed growth Family members may be of normal height. Skeletal bone age will lag behind the chronological age. Puberty may be delayed. Physical examination: Except for height, development is normal for age.

Constitutional growth delay

Iron (vitamins, prenatal vitamins) antidote

Evoke emesis Gastric lavage Whole bowel irrigation Deferoxamine Dialysis

Ages 5-25 years old Neoplasia in diaphysis of long bones, ribs, and flat bones

Ewing's Sarcoma

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 Treat with chemotherapy, surgery and radiation therapy

Ewing's Sarcoma

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

Ependymoma

DX: Diagnosis is based on MRI and histologic evaluation of biopsy TX: - Surgical resection, usually followed by radiation therapy - Sometimes chemotherapy The survival rate depends on age and on how much of the tumor can be removed: - Total or near-total removal: 51 to 80% survival - Less than 90% removal: 0 to 26% survival

Ependymoma

Mean age is 6 yrs however, about 30% occur in children < 3 yr Initial symptoms are typically related to increased intracranial pressure. Infants may present with developmental delay and irritability. Changes in mood, personality, or concentration may Seizures Balance and gait disturbances Symptoms of spinal cord compression (eg, back pain, loss of bladder and bowel control)

Ependymoma

The 3rd most common CNS tumor in children (after astrocytomas and medulloblastomas) Representing 10% of pediatric brain tumors

Ependymoma

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

Clinical findings: Sudden onset of high fever Respiratory distress Severe dysphagia Drooling Muffled voice Mild stridor with little or no coughing Patients usually sit upright with their necks extended.

Epiglottitis

Treatment: Avoid offending agent Burrow's solution (aluminum acetate) Topical steroids Zinc oxide (diaper rash)

Contact Dermatitis

Chronic cardiac or respiratory disease Hyponatremia Diarrhea, other systemic symptoms What kind of pneumonia?

Legionella pneumoniae

Pneumonia MC in air conditioning/aerosolized water

Legionella pneumoniae

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

Pruritic scalp, body or groin. Nits are observed as small white specs on the hair shaft Body (corporis); Pubic (pubis)

Lice

Chronic papulosquamous inflammatory dermatosis Appears as purplish, itchy, flat-topped bumps. On mucous membranes, such as in the mouth, it forms lacy white patches, sometimes with painful sores (wicham striae) Clinically characterized by 5Ps

Lichen Planus

Basal insulin Glargine (Lantus) duration: 24 hours Detemir duration: 12-24 hours

Long Acting Analog insulin

Pertussis antibiotic of choice

Macrolide (azithromycin, clarithromycin

Outpatient antibiotic for pneumonia patient who has underlying chronic disease

Macrolide + Beta lactam (e.g. penicillin, ceftriaxone)

Causes: (SIG-E-CAPS) Sleep (insomnia or hypersomnia) Interest (depressed mood) Guilt Energy (decreased) Concentration (decreased) Appetite (weight changes) Psychomotor (retardation or agitation) Suicidal ideation

Major Depressive Disorder

Treatment: Antidepressants should be continued for a minimum of 4 to 6 weeks to determine efficacy First line: SSRIs - SE: GI, HA, sexual dysfunction SNRI (Venlafaxine, Duloxetine) Atyptical antidepressant (Buproprion) TCAs - SE: weight gain, somnolence - overdosage is more lethal

Major Depressive Disorder

Starts and ends later than female puberty First sign of puberty in boys is increased testicular volume (~11.5 yr) Next: pubic/axillary hair and growth spurt (13.5 yr) Spermarche ~ 14 yr

Male Puberty

An elevated urine calcium suggests what?

Malignant neoplastic or paraneoplastic process Or hyperparathyroidism

The primary defect involves a connective tissue protein, resulting in tall, lanky stature; joint laxity; high arched palate; long digits; and myopia. Complications result from mitral valve prolapse, aortic root dilation, aortic insufficiency, aneurysms, and spontaneous pneumothorax.

Marfan Syndrome

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

Diagnosis: Clinical CT scan temporal bone with contrast for complicated/toxic appearing

Mastoiditis

Suppurative infection of mastoid air cell ⇒ usually a complication of acute otitis media Organisms: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, S. pyogenes Fever, otalgia, pain, erythema posterior to ear and forward displacement of the external ear

Mastoiditis

Treatment: Simple = oral antibiotics; IV antibiotics (ceftriaxone) ENT referral in more serious cases or pt with unreliable follow up Drainage of middle ear fluid

Mastoiditis

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

AKA Roseola

Measles

Etiology: Virus of its name Incubation Period: 8-14 days Prodrome: Fever, cough, anorexia, coryza (1-3 days) Rash: Maculopapular, face to extremities; Koplik spots in mouth

Measles

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 on buccal mucosa with blue-white pale center) precedes rash by 24-48 hours. Treatment is supportive - anti-inflammatories, isolate for 1 week after onset of rash

Measles

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

Pubic Hair Tanner Staging 3

More hair, darker, curly

Allow the infant's head to suddenly drop 1 to 2 cm, and observe for abduction at the shoulders and elbows along with spreading and extending of the fingers, followed by adduction and flexion of the same. This reflex disappears by 3 to 4 months of age.

Moro or startle reflex

MC primary malignant bone tumor

Multiple Myeloma

21-year-old male with a 2-day history of malaise and low-grade fever; develops swelling in the lower face bilaterally with the right side more pronounced. He now has a red, swollen duct on the inside of his right lateral mouth.

Mumps

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

Diagnosis: Can be made by determining recent exposure and parotitis. Usually, the disease is diagnosed on clinical grounds, and no confirmatory laboratory testing is needed As with any inflammation of the salivary glands, the serum level of the enzyme amylase is often elevated CSF demonstrates increased lymphocytes and decreased glucose

Mumps

MC of pancreatitis in children

Mumps

Prodrome of fever, malaise, and anorexia Parotid enlargement (usually bilateral but not always synchronous) 24 h later Swelling of submaxillary and submandibular glands Orchitis (usually unilateral) with testicular enlargement two to three times normal size

Mumps

Treatment: There is no available cure Treatment is supportive Contagious for up to 9 days after onset May need to provide scrotal support if painful or swollen testicle MMR vaccine is given at 12-15 months then again at 4-6 years of age

Mumps

Viral disease that is part of the paramyxovirus family Presents with: - parotitis (painful parotid gland swelling) - orchitis - aseptic meningitis Transmitted through respiratory droplets and has an incubation period of 12-14 days

Mumps

A form of abuse Usually perpetrated by the mother Symptoms are fabricated or clinical signs are induced in a child, resulting in repeated visits to a health care provider for relief. The perpetrator induces the various signs and symptoms to receive attention as being either an attentive or a suffering parent.

Munchausen syndrome by proxy

Impetigo tx

Mupirocin Dicloxacillin Cephalexin

Atypical mycobacterium found in fresh and saltwater Infection occurs after inoculation of the skin via abrasion or puncture in a patient with contact of an aquarium, saltwater, or marine animals Occupational hazard of aquarium handlers, marine workers, fishermen, and seafood handlers Diagnose by culture.

Mycobacterium Marinum

HIV patients with CD4 < 50 Fever, diarrhea, weight loss, anemia. Present in soil and water (not person to person) Symptoms rarely occur in immunocompetent patients (increased in bronchiectasis) Diagnose with AFB and culture

Mycobacterium avium complex (MAC)

Causes tuberculosis-like disease Treat with Rifampin + ethambutol

Mycobacterium kansasii

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

Low-grade fever Cough Bullous myringitis Cold agglutinins What kind of pneumonia?

Mycoplasma pneumoniae

Pneumonia MC in young adults, college setting

Mycoplasma pneumoniae Chlamydia pneumoniae

Muscle jerking, but not the tonic phase, occurs in the morning

Myoclonic Seizures

Symptoms daily Nighttime symptoms >1x/week FEV1 >60% FEV1/FVC reduced 5% Some limitation with daily activities What asthma classification?

Moderate Persistent

Common in dark-skinned infants and involve small to large, blue-black macules concentrated on the back and buttocks; these macules are frequently misdiagnosed as bruising. Most resolve spontaneously within 4 years, although they may persist for life.

Mongolian Spots

4-year-old boy with 3-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 also is 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.

Mononucleosis

AKA Epstein-Barr Virus Human herpes virus 4 Transmitted via saliva. AKA "kissing disease"

Mononucleosis

Clinical findings: Incubation period of several weeks Patients develop fever and sore throat Oral lesions include: - exudative pharyngitis - tonsillitis - gingivitis - soft palate petechiae Enlarged posterior cervical lymph nodes Complications - MC secondary bacterial pharyngitis (most commonly strep) - splenic rupture - pericarditis, myocarditis

Mononucleosis

Diagnostic studies: Early granulocytopenia Late lymphocytic leukocytosis Atypical lymphocytes - larger cells - stain darker - frequently vacuolated. Heterophile antibody screen usually are positive within 4 weeks False-positive syphilis test (VDRL or RPR) occurs in 10% of infected patients

Mononucleosis

Treatment: Nonaspirin antipyretics and anti-inflammatories. Antivirals decrease viral shedding, but do not affect the course of the illness. Patients with splenomegaly should avoid contact sports. Steroids are indicated - thrombocytopenia - hemolytic anemia - airway obstruction secondary to enlarged lymph nodes Prognosis is good. Although full recovery may take months

Mononucleosis

Life threatening Obtundation (reduced alertness) CO2 retention Coma Treatment: - thyroxine IV bolus

Myxedema Crisis

Persistent foul-smelling purulent unilateral nasal discharge in a young child without other respiratory symptoms should raise suspicion, even without a history of witnessed foreign body insertion

Nasal foreign body

Treatment: Prior to removal consider using oxymetazoline drops to shrink the mucous membrane

Nasal foreign body

Clinical features: Transient jaundice Acholic stools to liver failure Cirrhosis Portal hypertension Presenting features in the first week of life include jaundice and hepatomegaly The course of disease is generally self-limited, with full recovery during infancy

Neonatal Hepatitis

Idiopathic hepatic inflammation during the neonatal period. It is a diagnosis of exclusion and is the most common cause of cholestasis in the newborn. MC in males

Neonatal Hepatitis

Treatment: Management is supportive Decreased fat absorption may lead to growth failure and vitamin deficiencies. Ursodeoxycholic acid, a bile acid, is used to enhance bile flow and to reduce bile viscosity. Liver transplantation may be necessary in cases of severe liver failure.

Neonatal Hepatitis

Clinical features: Night pain is often associated with malignancy Painful mass attached to bone is likely to be malignant Severe pain preceded by dull, aching pain may indicate pathologic fracture. Rule out areas of metastases, such as the lungs, breasts, prostate, thyroid, and kidneys.

Neoplasia of the Musculoskeletal System

Diagnostic studies: Biopsy is essential to diagnose whether benign or malignant, the cell type, and the grade of lesion - Open incisional biopsy is best and should be done by a specialist. - The capsule is then closed tightly to prevent bleeding and local spread.

Neoplasia of the Musculoskeletal System

Imaging studies: Radiology CT is used to determine if pulmonary metastasis is present. MRI is used to determine the local extent of a tumor. Bone scans can evaluate distant osseous metastasis and noncontiguous tumor or skip lesions. They are not diagnostic in multiple myeloma.

Neoplasia of the Musculoskeletal System

Treatment: The goals of treatment are to relieve pain and maintain function For benign tumors, simple excision is the treatment Malignant neoplasms - Wide surgical resection is used when feasible. - Chemotherapy +/- radiation - Limb salvage (using cadaver allograft or endoprosthetic devices) is part of definitive treatment - Radiation therapy followed by local resection is the common treatment for soft-tissue sarcomas.

Neoplasia of the Musculoskeletal System

Clinical features: Diffuse or isolated, painless, persistent lymphadenopathy Bone marrow involvement is frequent. Common extralymphatic sites are the GI tract, skin, bone, and bone marrow. Burkitt = is likely to present with abdominal fullness.

Non-Hodgkin's Lymphoma

Diagnostic studies: Persistent, unexplained, enlarged nodes should be excised for histologic study. Staging is accomplished by: - chest radiography - CT of the abdomen and pelvis - bone marrow biopsy - possibly lumbar puncture.

Non-Hodgkin's Lymphoma

General characteristics: 90% of cases are derived from B lymphocytes. = higher with HIV and other immunodeficiencies 20 and 40 years of age. Divided into clinically indolent and aggressive groups. - Indolent = tend to convert to aggressive disease - Aggressive = 1/3 are curable with chemotherapy.

Non-Hodgkin's Lymphoma

Treatment: Indolent with one or two involved nodes - radiation alone. Intermediate- or high-grade - chemotherapy - immunotherapy - autologous stem cell transplantation

Non-Hodgkin's Lymphoma

MCV 80-100 Caused by: - organ failure (kidney, endocrine, or liver) - impaired marrow function - acute blood loss - chronic systemic disease elevating hepcidin in response to inflammation Parvovirus B19, chemo, toxins, aplastic anemia, pure red cell aplasia

Normocytic anemias

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 and complained 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

Child refuses to move the arm on presentation which is held in flexion and pronated Minimal swelling Significant pain Partial limitation of flexion/extension of the elbow Total loss of pronation/supination in the affected arm Diagnosis is made clinically and radiography is unnecessary unless is needed to exclude fractures or other dislocation.

Nursemaid Elbow

Dislocation of the elbow joint Caused by a sudden pull on the extended pronated forearm - an adult tugging on an uncooperative child - swinging the child by the arms during play MC age 1-3

Nursemaid Elbow

Treatment: The supination-flexion technique is the classic method Always ensure the child spontaneously uses the arm after reduction before discharging to confirm success

Nursemaid Elbow

radial head subluxation

Nursemaid Elbow

20% or more over ideal body weight or BMI > 30 Patients often suffer emotional distress over their eating binges but do not purge or restrict eating in an attempt to control their weight. They admit to a loss of control over their eating behavior.

Obesity

Diagnostic criteria: Recurrent episodes of binge eating at least once per week for 3 months Characterized by eating a larger amount of food in a 2-hour period Binge eating episodes are associated with three or more of the following: - eating faster than normal - eating until feeling uncomfortably full - eating to excess, even though not hungry - eating alone out of embarrassment - feeling disgusted, guilty, or depressed after the episode.

Obesity

Treatment: Behavior modification therapy Food diaries Development of new eating patterns (eating slowly, not eating between meals or when not seated) Implementation of a low-calorie, balanced diet and establishment of an exercise regimen are important. Pharmacotherapy - Sympathomimetics, such as amphetamine, dextroamphetamine, phentermine, phendimetrazine, and benzphetamine, can be used as adjuncts to suppress appetite. - Orlistat (Xenical) Surgical methods (gastric bypass and gastroplasty) have been beneficial for patients who are markedly obese.

Obesity

What three components comprise asthma?

Obstruction of airflow Bronchial hyperreactivity Inflammation of the airway

Full inspection of lids, conjunctiva, and cornea - Slit-lamp examination will assist in identification and removal X-ray or CT of may be necessary if there is evidence of penetration of the globe

Ocular foreign body

Metallic foreign bodies may leave a rust ring If you can't remove the foreign body easily then refer to the ophthalmologist

Ocular foreign body

Treatment: Attempt can be made to remove it by irrigation after the instillation of topical anesthetic (eg, sand) An attempt can then be made to remove the foreign body with a swab, using direct visualization Intraocular = require immediate surgical removal by an ophthalmologist Rust ring = should be treated as patients with corneal abrasions. The rust ring itself is not harmful and will usually resorb gradually

Ocular foreign body

Diagnostic criteria: At least 6 months of negativistic, hostile, and defiant behavior, including at least four of the following: - frequent loss of temper - arguments with adults - defying adults' rules - deliberately annoying others - easily annoyed - anger and resentment - spitefulness - blaming others for mistakes or misbehaviors.

Oppositional defiant disorder

This disorder generally begins before age 8 years and affects Will remit in 25%, but it also may progress to conduct disorder. High comorbidity with substance abuse disorders, mood disorders, and ADD and ADHD.

Oppositional defiant disorder

Treatment: Family intervention using training skills in child management for the parents/caregivers is crucial. Individual psychotherapy, focusing on behavioral modification and problem-solving skills, is recommended. Treat comorbid psychiatric disorders with medications as needed.

Oppositional defiant disorder

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

Oral Candidiasis

Candida albicans is a common yeast Infection is more likely in patients: - who wear dentures - those with diabetes - immunocompromised states - undergoing chemotherapy or radiation - undergoing treatment with corticosteroids or broad spectrum antibiotics.

Oral Candidiasis

Clinical features: Throat or mouth pain Appears as creamy white patches that can be scraped off to reveal underlying erythematous mucosa. The diagnosis is usually clinical, but wet prep or biopsy can be done.

Oral Candidiasis

Treatment: Antifungals - ketoconazole or fluconazole orally - clotrimazole troches - nystatin liquid rinses

Oral Candidiasis

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

Clinical features: Ptosis Eyelid edema Exophthalmos Purulent discharge Conjunctivitis. Fever Restricted range of motion in the eye muscles Edema Erythema of the lids and surrounding skin Sluggish pupillary response.

Orbital Cellulitis

Diagnostic studies: Workup: - CBC - blood cultures - cultures of any drainage - WBC count will be elevated CT is recommended to determine extent of disease. CT will show broad infiltration of the orbital soft tissue.

Orbital Cellulitis

MC age is 7 to 12 years. Primarily associated with sinusitis Other causes: - dental infections - facial infections - infection of the globe or eyelids - infections of the lacrimal system Causative agents: - Streptococcus pneumoniae - Staphylococcus aureus - Haemophilus influenzae

Orbital Cellulitis

Treatment Medical emergency requiring: - hospitalization - IV antibiotics (continued until fever subsides, then 2-3 wks of oral) - surgical drainage if recalcitrant or recurrent Inadequate treatment can lead to meningeal or cerebral infection. Recommended regimens include: - nafcillin and metronidazole or clindamycin - cephalosporin - fluoroquinolonea - If MRSA is suspected, treat with vancomycin.

Orbital Cellulitis

Pancreatic lipase inhibitor that decreases fat absorption from the GI tract Unpleasant side effect of oily stool leakage makes this less likely tolerated by patients.

Orlistat

To confirm the dislocation, Consists of flexing the baby's hip at 90° and then gently abducting it. This causes a reduction of the hip dislocation (CLICK auscultated)

Ortolani Maneuver

what 2 drugs are used for influenza A and B prophylaxis and treatment?

Oseltamivir and Zanamavir

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-Schlatter Disease

Apophysitis of the tibial tubercle caused by trauma or overuse MC age 8-15 MC males Self-limited disease, symptoms resolve when the epiphysis closes.

Osgood-Schlatter Disease

Clinical features: Anterior knee pain, with localized pain and swelling over the tibial tubercle. Pain is typically related to activity and is relieved with rest.

Osgood-Schlatter Disease

Imaging: Lateral radiography is usually normal but may show fragmentation at the tibial tubercle

Osgood-Schlatter Disease

Treatment: Activity modification for as long as several months Stretching, ice, and NSAIDs after exercise are indicated.

Osgood-Schlatter Disease

Benign Derived from aberrant cartilage MC 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 Treat with observation, resection if it becomes painful

Osteochondroma

This autosomal dominant defect involves type 1 collagen, resulting in bone fragility and pathologic fractures. Some cases result in blue-tinted sclera and varying degrees of deafness. In its severest form, fetal demise may occur.

Osteogenesis imperfecti

Ages 10-20 years old Neoplasia in the metaphyseal area of the long bones

Osteosarcoma

Progressively worsening night pain Bone pain/joint swelling Lung is the most common site of metastasis, followed by bone X-ray: sun ray/burst or hair on end appearance followed by bone scan look for metastasis Treat with limb-sparing resection or radical amputation

Osteosarcoma

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

AKA "swimmer's ear," Associated with water exposure, trauma (i.e., ear scratching/cleaning), or exfoliative skin conditions (e.g., psoriasis, eczema). Etiology: - Pseudomonas - Proteus - Fungi.

Otitis Externa

Clinical features Patients complain of ear pain (especially with movement of the tragus/auricle) Redness and swelling of the ear canal Purulent exudate

Otitis Externa

Treatment Treatment involves antibiotic otic drops (aminoglycoside e.g. -mycin or fluoroquinolone e.g. floxacin ± corticosteroids) Avoiding further moisture or ear injury. In diabetic or immunocompromised patients, malignant otitis externa may develop, which is a necrotizing infection extending to the blood vessels, bone, and cartilage - this requires hospitalization and parenteral antibiotics.

Otitis Externa

Hydrocarbons (benzene, gasoline, petroleum distillates) antidote

Oxygen with mist No emetics or lavage

What hyperthyroidism med should be taken during the first trimester of pregnancy?

PTU (SE: fulminant hepatic necrosis)

Clinical features: Pain, edema, tenderness, and erythema of the glans and foreskin are present. Identification of any encircling foreign bodies, such as hair, clothing, rubber bands, or metallic objects, is important

Paraphimosis

Entrapment of (inability to reduce) the foreskin behind the glans penis. Causes: - Frequent catheterizations without reducing the foreskin - Forcibly retracting a constricted foreskin (phimosis) for cleaning or catheterization - Vigorous sexual activity can predispose men

Paraphimosis

Entrapment of the foreskin in the retracted position

Paraphimosis

Treatment: Should be reduced emergently Manual reduction - should be tried initially - firmly squeeze the glans for 5 minutes to reduce the tissue edema and decrease the size of the glans - then try to bring the foreskin back over the glans Surgical techniques (dorsal slit) to incise the restricted foreskin can be used if manual reduction fails Inability to reduce = emergent urologic referral. After reduction, referral for circumcision is necessary because the condition is likely to recur.

Paraphimosis

Percentage of burn area × body weight (kg) × 4 mL/hour equals the total amount of fluid needed in the next 24 hours. Half fluid in first 8 hours Rest over remaining 16 hours

Parkland Formula

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). An echocardiogram

Patent Ductus Arteriosus

A failed or delayed closure of the channel bypassing the lungs, which allows placental gas exchange during the fetal state. Unlike other congenital anomalies, surgical treatment is usually not indicated as many patients respond to IV indomethacin. Noncyanotic Defects

Patent Ductus Arteriosus

Diagnose: - Echocardiogram Treatment: - Indomethacin has been used to help close

Patent Ductus Arteriosus

Higher in premature infants Continuous (machinery) murmur in patients Wide pulse pressure Hyperdynamic apical pulse

Patent Ductus Arteriosus

Characterized by involvement of four or fewer medium to large joints Patients are at risk for development of asymptomatic uveitis that may lead to blindness if they have a positive antinuclear antibody (ANA) test. What type of Juvenile Rheumatoid Arthritis?

Pauciarticular

Treatment: Topical metronidazole, avoid steroids Mild: topical ALONE 1st line - Topical Pimecrolimus - Erythromycin - Metronidazole - Clindamycin - Oral ABX: Doxycycline if necessary - no gels, solutions, or lotions on eye Moderate: - topical + oral ABX

Perioral Dermatitis

Young women Papulopustular, plaques, and scales around the mouth Lip margin (vermillion border) is spared DX: clinical, a biopsy may help

Perioral Dermatitis

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 a muffled (hot potato) voice, and extreme difficulty opening his mouth (trismus). He opens it just far enough for you to note uvular deviation.

Peritonsillar Abscess

AKA Quinsy abscess

Peritonsillar Abscess

Clinical features: Significant sore throat Pain with swallowing Trismus Deviation of the soft palate/uvula Muffled "hot potato" voice. Deviation of the soft palate and asymmetric rise of the uvula are highly suggestive

Peritonsillar Abscess

Results from penetration of infection through the tonsillar capsule and involvement of neighboring tissue

Peritonsillar Abscess

Treatment: Aspiration Incision and drainage Antibiotics - Amoxicillin - Augmentin - Clindamycin Tonsillectomy may also be considered

Peritonsillar Abscess

Lice tx

Permethrin

Graves Disease Labs

Peroxidaase antibodies Thyroglobulin antibodies

24-year-old with an increasing cough for 3 weeks. The cough comes and goes sometimes lasting for 10 minutes and causing gasping inhalations. The cough was preceded by a mild cough and cold 2 weeks ago. She has completed all immunizations required to attend school and has no known drug allergies

Pertussis

Clinical findings: The catarrhal stage: Insidious onset of sneezing, coryza, loss of appetite, and malaise along with a hacking cough most prominent at night. This stage is often misdiagnosed as an upper respiratory viral illness. This is the most infectious stage. The paroxysmal stage: Spasms of rapid coughing fits followed by deep, high-pitched inspiration (the whoop). Paroxysms may last several minutes. Infants are at risk for apnea. The convalescent stage: Decrease in frequency and severity of paroxysms; this stage begins usually 4 weeks after the onset of the cough and may last for an additional several weeks. Physical exam is generally unremarkable. Fever is rare.

Pertussis

Diagnostic studies: Culture using a special media. PCR assays may be available through some health departments. WBC count is usually mildly elevated; a lymphocytosis is characteristic.

Pertussis

Gram-negative pleomorphic bacillus Humans are the sole reservoir Infection is highest in premature infants and in those with cardiac, pulmonary, or neuromuscular disorders. Older children and adults tend to have milder disease.

Pertussis

Treatment: A macrolide (azithromycin, clarithromycin) is the medication of choice. A supportive therapy is essential. Close contacts should also be treated with a macrolide. Prevention - DtaP in infancy - Tdap in adults (every 10 years)

Pertussis

Clinical features GABHS-suggestive manifestations include: - fever (>38°C or 100.4°F) - tender anterior cervical adenopathy - lack of cough - pharyngotonsillar exudate. > 3 = can treat empirically Coryza, hoarseness, and cough are not suggestive of strep

Pharyngitis

Diagnostic studies Rapid streptococci screening for GABHS has 90% to 99% sensitivity. If negative and Group A Streptococci is still suspected, throat culture is confirmatory.

Pharyngitis

Sore throat, a common reason for outpatient visits, is associated with about half of outpatient antibiotic use Etiology is more commonly viral than bacterial. It is important to differentiate and treat cases that are caused by group A β-hemolytic streptococci (GABHS) to prevent complications as well as to limit unnecessary antibiotic use.

Pharyngitis

Treatment: First line: Penicillin or Cefuroxime Allergy: Erythromycin or other macrolide IM penicillin can be used if patient compliance is in doubt Inadequate treatment can lead to complications: - scarlet fever - glomerulonephritis - acute rheumatic fever - abscess formation

Pharyngitis

Moderate to severe intellectual disability, hyperactivity, seizures, autism, and hypopigmentation Dx: Test after 24 hours of protein intake, then quantitative serum phenylalanine determination Tx: Lifetime of low-protein diet; avoid products with phenylalanine

Phenylketonuria

Clinical features: Erythema with tenderness and possible purulent drainage around the glans/foreskin Inability to retract the foreskin over the glans penis Severe Constriction - Obstructed urinary stream - Hematuria - Pain of the prepuce (foreskin) can indicate more severe constriction.

Phimosis

Foreskin in normal position that cannot be retracted

Phimosis

Inability to retract the foreskin over the glans penis Congenital - in children and adolescents - usually physiologic Acquired - more typical in adults and - usually caused by poor hygiene and chronic balanitis - Consider evaluation for possible diabetes in men with chronic infections

Phimosis

Treatment: Asymptomatic congenital - should be left alone - as the preputial opening will gradually widen as the child gets older Symptomatic - referral for circumcision is usually necessary - Broad spectrum antibiotics are indicated if infection is present - Steroidal creams or nonsteroidal ointments may be of benefit

Phimosis

What is the hallmark of iron deficiency anemia?

Pica

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 but scratches his buttocks while you are interviewing. Cellophane tape applied to the perianal area reveals football-shaped ova under the microscope.

Pinworms (enterobiasis)

Clinical findings: Many patients are asymptomatic. Perianal pruritus (crawling sensation that is worse at night) Insomnia Weight loss Enuresis Irritability. Examination at night may reveal worms in the anus or in the stool. Scratching causes excoriations and secondary skin infections (i.e., impetigo).

Pinworms (enterobiasis)

Diagnostic studies: Eggs can be captured on a piece of cellophane tape over the perianal skin Three tries over three consecutive nights yield 90% success rate.

Pinworms (enterobiasis)

Humans are the only host for Enterobius vermicularis Adult worms are loosely attached to the mucosa, primarily in the cecum Gravid females pass through the anus to lay eggs on the perianal skin. Infection is easily passed through hands, food, drink, and fomites. The eggs are swallowed and hatch in the duodenum; larvae pass to the cecum and mature in 3 to 4 weeks. The lifespan is 30 to 45 days

Pinworms (enterobiasis)

Treatment a.All members of the household should be treated concurrently. b.Albendazole, mebendazole, or pyrantel is administered in a single dose and then repeated 2 to 4 weeks later. c.Hand washing after defecation and before meals must be stressed. Bed sheets should be washed thoroughly.

Pinworms (enterobiasis)

Occurs in children and young adults. Initial herald patch, followed by the development of a diffuse papulosquamous rash. Easier to identify when the general eruption appears with smaller secondary lesions that follow Langer's lines (cleavage lines) in a Christmas tree-like pattern.

Pityriasis Rosea

Treatment: The disease is self-limiting Topical or systemic steroids and antihistamines are often used to relieve itching. Asymptomatic lesions do not require treatment

Pityriasis Rosea

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

What should be avoided in thrombocytopenia?

Platelet antagonist (aspirin, NSAIDs)

Slower onset, immunosuppression Increased lactate dehydrogenase More hypoxemic than appears on chest radiography Interstitial infiltrates MC in HIV with CD4 <200 What kind of pneumonia?

Pneumocystis jiroveci

Denotes inflammation in the alveoli or interstitium of the lung caused by microorganisms that infect the lower respiratory tract. Leading cause of morbidity and mortality worldwide.

Pneumonia

Resembles adult RA with its symmetric involvement and involves five or more of the small and large joints Systemic symptoms include: - low-grade fever - fatigue - rheumatoid nodules - anemia What type of Juvenile Rheumatoid Arthritis?

Polyarticular

Clinical features: Epistaxis may be the presenting complaint. Generalized pruritus after bathing is characteristic. Incidence of PUD is high MC complication = thrombosis Headache Dizziness Fullness in head and face Weakness/fatigue Tinnitus Blurred vision Burning pain Redness of the extremities Splenomegaly Plethora Engorged retinal veins Systolic HTN

Polycythemia Vera

Diagnostic studies Hematocrit levels - Males > 54% - Females > 51% Primary - thrombocytosis (platelets high) - leukocytosis - peripheral smear shows neutrophilic leukocytosis, increased basophils and eosinophils, and increased number of large platelets Red cell morphology is usually normal EPO levels are generally low. Hyperuricemia can also develop

Polycythemia Vera

Slowly progressive bone marrow disorder Characterized by increased numbers of RBCs and increased total blood volume. - hyperviscosity - decreased cerebral blood flow - hypercoagulability JAK2 mutation is diagnostic for the primary (genetic) cause. Secondary causes - chronic hypoxia - cigarette smoking - living at high altitudes - renal tumors MC cause of death = thrombosis May convert to CML

Polycythemia Vera

Treatment: First line: Serial phlebotomy Myelosuppressive therapy with hydroxyurea may be indicated Low-dose aspirin reduces the risk of thrombosis.

Polycythemia Vera

Treatment: Posterior packing is more difficult and carries high risk for complications - specialist evaluation and inpatient monitoring are recommended With life-threatening cases of continued bleeding, surgery is indicated (i.e., nasal arterial supply ligation).

Posterior Epistaxis

Group A strep - 10-14 days after infection - diagnosed with ASO titers and low serum complement Treatment is supportive + antibiotics

Postinfectious

Initial episode may be asymptomatic or severe, with a prodrome of systemic and local symptoms. Preexisting antibodies to HSV-1 may have an ameliorating effect on the severity of primary HSV-2 infection Vesicles rupture and form tender ulcers, which crust over. Mucosa may be red and edematous. Females tend to have more severe disease and higher rates of complications. The cervix is involved in more than 70% of female patients, manifesting as ulcerative or necrotic mucosa.

Primary genital herpes

A decreased urine calcium suggests what?

Primary hyperparathyroidism

How do you diagnose both viral and bacterial meningitis?

Prompt LP and CSF analysis

Carcinomas that commonly metastasize to the bone

Prostate Breast Lung Kidney Thyroid

Pneumonia MC in Cystic Fibrosis

Pseudomonas sp.

Four features of tetralogy of fallot (PROVe)

Pulmonary Stenosis RVH Overriding aorta Ventricular septal defect

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

Congenital condition where a newborn's pylorus undergoes hyperplasia and hypertrophy Leading to obstruction of the pyloric valve which causes vomiting (that might be projectile), as well as dehydration and metabolic alkalosis

Pyloric Stenosis

Diagnosis: Diagnosis is by ultrasound On ultrasound, you will see a "double-track" Barium studies will reveal a "string sign" or "shoulder sign" Labs: Hypochloremic, hypokalemic metabolic alkalosis (secondary to dehydration)

Pyloric Stenosis

Projectile vomiting occurs shortly after feeding in an infant < 3 mo old with a palpable "olive-like" mass at the lateral edge of the right upper quadrant Pediatric patients < 3 months old - Nonbilious projectile vomiting after most or every feeding - Physical exam - palpable epigastric olive-shaped mass (is pathognomonic for the disorder)

Pyloric Stenosis

Treatment: Surgical correction - pyloromyotomy (Ramstedt's procedure)

Pyloric Stenosis

what is a major consideration when prescribing a macrolide?

QTc prolongation

what 2 drug interactions should you be careful of with flouroquinolones?

QTc prolongers and multivalent cation drugs (decreased absorption)

Take 15-20 minutes before meals Duration 5-8 hours, up to 12 hours Regular

Regular Insulin (short acting)

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

Caused by an orthomyxovirus Occurs in epidemics and pandemics during the fall or winter. Three strains exist (A, B, and C) and are typed based on the surface antigens hemagglutinin (H) and neuraminidase Public health authorities: - follow changes in strains to predict new virus and steer vaccine development - monitor outbreaks - responsible for alerting the public about emerging strains.

Influenza

Clinical findings: Abrupt fever Chills Malaise Muscle aches Substernal chest pain Headache Nasal stuffiness Wheezes and rhonchi may be heard, Children often develop diarrhea

Influenza

Diagnostic studies: Leukopenia Proteinuria Rapid antigen test - virus isolated from the throat or nasal mucosa

Influenza

Treatment Supportive care with rest, analgesics, and cough suppressants as needed. Neuraminidase inhibitors (zanamivir inhalation or oral oseltamivir) - administered within 48 hours of the onset of symptoms. - effective against A and B - CI: patients less than 12 Prevention through cavvine" - administered to all the patients yearly in October or November - especially recommended for all people more than 65 years of age, children or adolescents on chronic aspirin therapy, nursing home residents, patients with chronic lung or heart disease, and all health care workers - CI: egg allergy, acute febrile illness

Influenza

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 a bulge 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

Symptoms </=2 days/week Nighttime symptoms </=2/month FEV1 >80% FEV1/FVC normal No interference with daily activities What asthma classification?

Intermittent

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

Clinical features: Children - Signs of severe colicky pain - Stool, if passed, will contain mucus and blood (currant jelly stools) - Sausage-like mass may be felt on abdominal examination. Adults - more indolent course of crampy abdominal pain. - Bloody stool and abdominal mass are rare.

Intussusception

Diagnostic studies: For children - barium or air enema may be both diagnostic and therapeutic. For adults - barium enema should not be used - CT is the best means of establishing the diagnosis, but many cases are diagnosed only at surgery.

Intussusception

The invagination of a proximal segment of the bowel into the portion just distal to it. MC in children (95% of cases), generally following a viral infection In adults, almost always is caused by a neoplasm.

Intussusception

Treatment: All patients should be hospitalized. Air or barium enema may be curative for children; if not, surgery is needed. Adults generally require surgery

Intussusception

Microcytic Anemia ↓ Iron ↑ TIBC < 16% Saturation ↓ Ferritin Normal Hemoglobin Normal Indirect bilirubin LDH

Iron Deficiency Anemia

Treatment: Ferrous sulfate 325 mg 3/day Best absorbed on an empty stomach Supplemental Vit C for absorption Common SE: Constipation

Iron Deficiency Anemia

what is the DOC for latent TB? how long do pts take it?

Isoniazid; 9 months

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

Diagnostic Studies: Serum total and unconjugated bilirubin Urinary bilirubin indicates that conjugated hyperbilirubinemia present CBC, LFTs, albumin, PT/INR, GGT, alkaline-phosphatase, hepatitis panel Abdominal ultrasound (preferred) or CT abdomen Liver biopsy (definitive)

Jaundice

Yellowish discoloration of the skin The first sign = scleral icterus If suspected a second site is under the tongue Indicates serum bilirubin > 2 mg/dl

Jaundice

Criteria for diagnosis: - Two major OR one major plus two minor AND evidence of recent strept infection Major criteria - Carditis (diagnosed by echocardiogram) - Erythema marginatum - Subcutaneous nodules - Chorea - Polyarthritis Minor criteria - Fever - Polyarthralgias - Reversible prolonged PR interval - Rapid ESR - C-reactive protein

Jones Criteria

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

Characterized by: - chronic synovitis - a number of extra-articular manifestations (fever, rash, weight loss, other organ involvement) MC in females Onset in females 1-3 y.o. Onset in males 8-12 y.o.

Juvenile Rheumatoid Arthritis

Clinical features: Younger than 16 years old Symptoms for >6 weeks Three subtypes: - Systemic 15% (Still disease) - Pauciarticular 50% (4 or fewer joints) - Polyarticular 35% (5+ joints)

Juvenile Rheumatoid Arthritis

Diagnostic studies: No specific 10% to 15% of patients have a positive RF ACPA antibody test may be positive ESR and CRP are increased or normal with the systemic type. Imaging studies - may be similar to those for adults with soft-tissue swelling and periarticular osteoporosis findings - joint destruction is less frequent.

Juvenile Rheumatoid Arthritis

Treatment: First line: - NSAIDs - Physical and occupational therapy Second line: - Methotrexate - Leflunomide - Anakinra may Monitor for: - growth abnormalities - nutritional deficiencies - school/social impairment 75-80% remit (greatest risk for not remitting = + RF

Juvenile Rheumatoid Arthritis

.Fever (>5 days) in addition to at least four of the following symptoms are needed to make a diagnosis: - conjunctivitis - lip cracking and fissuring - strawberry tongue - inflammation of the oral mucosa - cervical lymphadenopathy, usually unilateral - polymorphous exanthem - redness and swelling of the hands and feet with subsequent desquamation Cardiovascular manifestations are worrisome (two-dimensional echocardiography or angiography is recommended)

Kawasaki Disease

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 and feet. 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

Treatment is with IV immunoglobulin and high-dose aspirin; early treatment reduces the chance of cardiac events. Patients with cardiac disease should receive long-term aspirin therapy and annual follow-up. f.Patients should be monitored through serial electrocardiography, chest radiography, and echocardiography until they recover.

Kawasaki Disease

Anterior epistaxis occurs where?

Kiesselbach plexus

Currant jelly sputum Chronic illness, including alcohol abuse What kind of pneumonia?

Klebsiella pneumoniae

Pneumonia most common in alcohol abuse

Klebsiella pneumoniae

Initially tall, thin, and long limbed; become obese in the adult years. Scoliosis is frequent. Ataxia, expressive language disorders, and usually mild developmental delay are characteristic. Males exhibit small penis, hypogonadism, oligospermia or azoospsermis, scant pubic and facial hair, and gynecomastia. Behavior concerns are frequent including learning disabilities, language problems, poor self-esteem, and substance abuse.

Klinefelter syndrome (XXY)

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

Diagnosis: ↑ serum blood lead level (BLL) Basophilic stippling ↓ or normal MCV ↓ mean MCH Hemolysis - ↑ indirect bilirubin, LDH - ↓ haptoglobin

Lead Poisoning

MC environmental illness of children in the United States In children, most organs are susceptible, especially the brain. Environmental exposure is the most significant source in children, including exposure to paint, food, water, and soil Classic case scenarios = children inside an old house with paint chips

Lead Poisoning

Symptoms in children non-specific and include: Behavioral changes Temperamental lability Irritability Hyper/hypoactivity Developmental delays Abdominal pain Vomiting Constipation Lethargy Headache Ataxia Seizures Anemia

Lead Poisoning

Treatment: Preventing further exposure Chelation therapy Dietary measures Contact with the local health department is only necessary when patients have a blood level of greater than 20 μg/dL, or if after 3 months the levels remain elevated Siblings and other children who live in the household or attend the same school or daycare should be tested

Lead Poisoning

Sideroblastic anemia is what until proven otherwise?

Lead toxicity (other cause: alcohol)

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, subcostal and intercostal retractions are noted. Expiratory wheezes and a cough are present.

Respiratory Syncytial Virus

MC cause of lower respiratory tract infection in children worldwide - virtually all children get it by age 3 Leading cause of pneumonia and bronchiolitis

Respiratory Syncytial Virus

Rhinorrhea Wheezing/coughing that persists for months Low-grade fever Nasal flaring/retractions Nail bed cyanosis Diagnosed with nasal washing, antigen test; CXR can show diffuse infiltrates

Respiratory Syncytial Virus

Treatment: Indications for hospitalization - tachypnea with feeding difficulties - visible retractions - oxygen desaturation < 95-96% Supportive measures: - albuterol via nebulizer - antipyretics and humidified oxygen - steroids (controversial) - resolves in 5-7 days

Respiratory Syncytial Virus

Pneumonia MC in children <1 year

Respiratory syncytial virus

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

Malignancy of the retina of the eye Often presents in children less than 3 years of age Physical exam - leukocoria (absence of red-light reflex)

Retinoblastoma

Treatment: Surgical enucleation of the eye (removal of the eye that leaves the eye muscles and remaining orbital contents intact) Chemotherapy

Retinoblastoma

Defined as a fatty liver with encephalopathy. May develop 2 to 3 weeks after the onset of influenza A or varicella infection, especially if aspirin is ingested Rapidly progressive 30% fatality rate Peak age is 5 to 14 years Rarely occurs past 18 years of age Treatment is supportive

Reye Syndrome

what are the drugs used to treat active TB?

Rifampin, Isoniazid, Pyrazinamide, Ethambutol (RIPE)

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, excoriations in his web spaces of hands and feet, axillae & groin. Lesions do not appear to be infected.

Scabies

Pruritic papules S-shaped or linear burrows on the skin Often located in web spaces of hands, wrists, waist Severe itching (worse at night) Diagnose with microscopic observation of mite, egg or feces after skin scrape

Scabies

Treatment: Topical permethrin 5% All clothing bedding, towels washed and dried using heat and have no contact with body for at least 72 hours Oral ivermectin - for adults and children weighing at least 33 pounds who can swallow pills - OK for nursing women, but avoid in pregnancy

Scabies

Clinical features: 6 months after birth when protective Hgb F levels fall to adult levels Mild to severe complications - vascular occlusions - painful crises - strokes - chest syndrome - bone infarctions - avascular necrosis (AVN) - splenic sequestration - delayed growth/puberty Patients should avoid high altitudes and deep-sea diving. Life expectancy for type SS is 40 to 50 years of age

Sickle Cell Anemia

Diagnostic studies: Electrophoresis demonstrates the level of different hemoglobins in the red cell - Hgb S is 50% or greater Peripheral smear may reveal: - sickled cells (5% to 50%) - target cells - nucleated RBCs - Howell-Jolly bodies Reticulocyte count, indirect bilirubin, and LDH are elevated when hemolyzing. White blood cell (WBC) count is elevated

Sickle Cell Anemia

Family of autosomal recessive inherited hemoglobinopathies (SS, SC, SD, SO Arab, S β+ thalassemia, and S β0 thalassemia) RBCs containing primarily Hgb S sickle under hypoxia, dehydration, acidosis, and extreme temperature conditions MC in African Americans

Sickle Cell Anemia

Treatment: Symptomatic treatment of pain episodes includes administration of analgesics, hypotonic fluids, and rest. May require transfusion or exchange transfusion. Low-dose daily penicillin from birth until 6 years of age Pneumococcal vaccine (booster every 10 years) Transcranial Doppler screening for stroke Pulmonary function testing (PFT) for restrictive disease screening Chronic folate supplementation

Sickle Cell Anemia

Microcytic Anemia Dimorphic stippling of RBCs ↑/Normal Iron Normal TIBC 50-100% Saturation ↑ Ferritin Normal Hemoglobin Normal Indirect bilirubin LDH

Sideroblastic Anemia

Treatment: Chelation therapy for lead toxicity Removal of toxin Pyridoxine (Vitamin B6)

Sideroblastic Anemia

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

Clinical features: A history of insidious hip, thigh, or knee pain associated with a painful limp.

Slipped capital femoral epiphysis

Imaging: Lateral radiographs - posterior and medial displacement of the epiphysis Best assessed with the patient in the frog-leg lateral pelvis or lateral hip view.

Slipped capital femoral epiphysis

Treatment: Definitive = pinning in situ. Child should be placed on crutches and should avoid weight-bearing before and after surgery.

Slipped capital femoral epiphysis

Weakening of the epiphyseal plate of the femur Resulting in a displacement of the femoral head May be bilateral. MC 10-16 y.o. MC in boys MC in African Americans MC in athletes MC in obese Most cases are idiopathic, but in the younger child, consider a metabolic cause (hypothyroidism or hypopituitarism).

Slipped capital femoral epiphysis

What does von willebrand factor do?

Stabilizes factor 8, low levels can cause psuedohemophilia A

Diagnosed when seizures fail to cease spontaneously or recur so frequently that full consciousness is not restored between successive episodes. The length of time seizure activity must persist to diagnose is generally more than 5 minutes. Benzodiazepines (lorazepam) are the preferred initial treatment after which typically phenytoin is given

Status Epilepticus

Hypersensitivity complex that affects the skin and the mucous membranes Commonly caused by anticonvulsants and sulfa drugs! 3-10% of the body Begins with a prodrome of flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Layers of skin peel away in sheets (+) Nikolsky's sign (pushing blister causes further separation from dermis) Milder form of TEN

Stevens-Johnson Syndrome

60-year-old woman with a severe drug-induced reaction on both lower limbs with few lesions elsewhere in addition to mucosal involvement of the mouth of two days duration. The insulting drug was sulfonamide and the onset of the rash was within 48 hours of taking the drug. The rash comprised of bilateral symmetrical bullae on a background of erythematous macules and patches in addition to erosions and peeling.

Stevens-Johnson syndrome

Loudest in the apex and left sternal border Grade I to III Musical or vibratory, high-pitched, early systolic murmur Diminishes with sitting, standing, or Valsalva maneuvers Accentuates with fever

Still's murmur

most common innocent murmur of childhood.

Still's murmur

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 condition in which binocular fixation is not present. May occur in one eye or both Corneal light reflex test will reveal misalignment Cover-uncover test may reveal latent versions Inward misalignment = esotropia Outward misalignment = exotropia

Strabismus

Treatment: May be corrected with eye exercises (patch therapy) Severe cases, with surgery. If left untreated after the age of 2 years, amblyopia will result.

Strabismus

Single rigor Rust-colored sputum What kind of pneumonia?

Streptococcus pneumoniae

Diagnostic Studies Tests include: - electrocardiography - ambulatory monitoring (Holter) - echocardiography - tilt-table test - electrophysiologic studies - possibly CT or MRI of the brain Treatment varies with the cause.

Syncope

Sudden, transient loss of consciousness not resulting from trauma. Common causes: - arrhythmias - aortic stenosis - carotid sinus hypersensitivity - myocardial infarction - hypoglycemia - orthostatic hypotension - postprandial hypotension - pulmonary embolus

Syncope

Characterized by: - spiking fevers (39° to 40°C; 102.2° to 104°F) - myalgias - polyarthralgias - typical salmon-pink maculopapular rash appearing in the evening and with the fever Rash may be elicited by scratching the skin in susceptible areas (Koebner phenomenon). Minimal articular findings, but hepatosplenomegaly, lymphadenopathy, leukocytosis, pericarditis, or myocarditis may occur. What type of Juvenile Rheumatoid Arthritis?

Systemic

MC types of scoliosis

Right thoracic curves (T7 or T8)

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

Etiology: Human herpes virus 6 or 7 Incubation Period: 10-14 days Prodrome: Fever (4 days) Rash: Pink, macular rash Comments: Fever resolves before 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

Causes - impaired marrow production (e.g., vitamin B12 or folate deficiency; congenital; or marrow damage from drugs, leukemia, infections) - increased destruction (e.g., immune-mediated HIT, ITP, HIV, SLE, or nonimmune in DIC, TTP, and HELLP) - hepatosplenic sequestration.

Thrombocytopenia

Clinical features Below 50,000/μL - petechiae, purpura - bleeding (nose, gums, GI tract, menorrhagia) - Caused by TTP, HELLP, HIT, HUS, and DIC

Thrombocytopenia

Adults Cause: ADAMTS 13 and big vWF Normal PT/PTT Fever Bleeding and clotting disorder CNS failure Treatment - emergent plasma exchange - no platelets

Thrombotic thrombocytopenic purpura (TTP)

Extreme hyperthyroidism High fever Tachycardia Tremor Delirium N/v Mortality is high Treatment: - PTU given orally - Propanolol - IV Sodium IOdide

Thyroid Storm

A highly contagious, fungal infection of the skin or scalp. KOH - long, branching fungal hyphae with septations

Tinea Infections

Athlete's Foot: pruritic scaly eruptions between toes. Trichophyton rubrum is the most common dermatophyte cause Mgmt: Topical antifungals

Tinea Pedis

Caused by Malassezia furfur, a yeast Hypo or hyperpigmented macules that do not tan. Seen in adolescents and young adults Scaling, oval patches Distributed on the upper trunk, neck, and proximal arms and in areas where there is a high amount of sebum and free fatty acids, which the organism requires; occasionally on the face

Tinea Versicolor

AKA convulsive seizures (formerly known as grand mal) Bilaterally symmetric and without focal onset Begins with a sudden loss of consciousness—a fall to the ground Tonic phase: very stiff and rigid 10-60 seconds. Clonic phase: generalized convulsions and limb jerking Postictal phase: a confused state

Tonic-Clonic Seizures

60-year-old woman with a severe drug-induced reaction with extensive skin involvement covering > 30% of her body surface area. The insulting drug was anticonvulsant medication and the onset of the rash was within 10 days of taking the drug. The rash comprised of bilateral symmetrical bullae on a background of erythematous macules and patches in addition to erosion and peeling. On examination, her skin peels away in sheets when pressure applied and rubbed.

Toxic Epidermal Necrolysis

Rare, life-threatening skin condition that is usually caused by a reaction to drugs > 30% of body Very similar to Steven-Johnson syndrome - The difference is the age of the individuals (SJS younger patient) - percentage of the body affected (SJS < 10% of body surface area affected)

Toxic Epidermal Necrolysis

Acetaminophen toxicity: Treatment with N-Acetylcysteine within 8-10 hrs

Toxic Hepatitis

Aotherwise-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 reducible and a defect was felt through the umbilicus.

Umbilical Hernia

Congenital and appears at birth Many resolve on their own, but surgery may be indicated What kind of hernia?

Umbilical Hernia

Skin rash triggered by a reaction to certain foods, medications, stress, or other irritants Blanchable, pruritic, raised, red, or skin-colored papules, wheels or plaques on the skin's surface (+) Darier's sign Angioedema

Urticaria (Hives)

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 pruritis and the mother is encouraged to eliminate citrus from his diet. The rash resolves within 72 hours.

Urticaria (Hives)

which antibiotic causes Red Man Syndrome?

Vancomycin (Van the Red Man)

AKA Chicken Pox

Varicella

Etiology: A human herpes virus Incubation Period: 10-21 days Prodrome: Fever, respiratory symptoms (1-3 days) Rash: Vesicular erythematous, torso and face to extremities (dew drop on rose petal) Comments: Pruritic

Varicella

lack of immune deposits (+) ANCA antibodies

Vasculitis

MC cause of syncope

Vasovagal (neurocardiogenic)

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. An echocardiogram is performed

Ventricular Septal Defect

DX: - Echocardiogram Treatment: - Most close by age 6, surgery if large

Ventricular Septal Defect

May be perimembranous (most common), muscular, or outlet openings between the ventricles. Noncyanotic Defects

Ventricular Septal Defect

Most common of all congenital heart defects

Ventricular Septal Defect

Systolic murmur at LLSB Depends on size of defect—from asymptomatic to signs of CHF Outlet = more common in Japanese and Chinese

Ventricular Septal Defect

Flat warts Hands, face, arms, legs

Verruca plana

Plantar warts Bottom of the foot. Rough surface. Dark spots (thrombosed capillaries)

Verruca plantaris

Common warts Skin-colored papillomatous papule

Verruca vulgaris

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

AKA Warts

Verrucae

Treatment: - Most resolve without treatment over 2 years - Cryotherapy with liquid nitrogen may be applied with a cotton swab or with a cryotherapy gun (Cryogun) - Self-administered topical therapy such as salicylic acid

Verrucae

Main categories of dizziness

Vertigo Disequilibrium Presyncope Lightheadedness

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

Diagnosis: Diagnose by using VCUG (Voiding Cysto-Urethrogram) Monitor by using serial ultrasonography and VCUGs

Vesicoureteral reflux

Treatment: Mild to moderate resolves spontaneously More serious disease may require surgical intervention Newly diagnosed children are given prophylactic antibiotics depending on their clinical course

Vesicoureteral reflux

Urine flows retrograde, or backward, from the bladder into the ureters/kidneys In young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for this

Vesicoureteral reflux

CSF Analysis: Clear color Normal pressure Normal to mildly elevated WBC count, lymphocytes or monocytes Normal protein Normal glucose

Viral (Aseptic) Meningitis

Clinical features: Acute confusional state, especially in children and young adults. Symptoms may have persisted for several days Number of systemic manifestations, suggesting a particular causal agent (e.g., rash, pharyngitis, adenopathy, pleuritis, carditis, jaundice, organomegaly, diarrhea) In encephalitis, because it involves the brain directly, there may be: - markedly altered consciousness - seizures - personality changes

Viral (Aseptic) Meningitis

MC cause - enteroviruses (coxsackievirus A or B, echoviruses) - herpes simplex virus type 2 - arthropod-borne viruses May also reflect an inflammatory process in the parameningeal area (i.e., sinusitis, otitis, abscess). Encephalitis frequently associated with childhood exanthems, arthropod-borne agents, and herpes simplex virus type 1.

Viral (Aseptic) Meningitis

Treatment: With the exception of infection with herpes simplex virus, the course is generally benign and self-limited, and no specific therapy is required Acyclovir for herpes virus Acetaminophen for headache Anticonvulsants for seizures Support breathing if necessary

Viral (Aseptic) Meningitis

- HBeAg - highly infectious - HBsAg - ongoing infection - Anti-HBc - had/have infection - IgM - acute - IgG - not acute - Anti-HBs - immune

Viral Hepatitis

Clinical features Pruritis Pale stool Tea-colored urine Vague abdominal discomfort Fatigue Malaise Anorexia Nausea

Viral Hepatitis

Diagnosis: ALT and AST elevations are seen in all types, indicating hepatocellular damage. Bilirubin of greater than 3.0 mg/dL will be associated with scleral icterus, if not frank jaundice US and MRI of the liver

Viral Hepatitis

Dx: - CXR = bilateral interstitial infiltrates - Rapid antigen testing for flu - RSV nasal swab - cold agglutinin titer negative Tx: - flu with Tamiflu (A and B) if sx's began < 48 hrs - symptomatic tx = beta 2 agonists - fluids, rest

Viral Pneumonia

Clinical features Acute onset of unilateral or bilateral erythema of the conjunctiva Copious watery discharge Ipsilateral tender preauricular lymphadenopathy.

Viral conjunctivitis

Treatment Eye lavage with normal saline twice a day for 7 to 14 days Vasoconstrictor-antihistamine drops also may have beneficial effects. Warm to cool compresses reduce discomfort.

Viral conjunctivitis

Usually is caused by adenovirus type 3, 8, or 19. Highly contagious Transmission is by direct contact, usually via the fingers, with the contralateral eye or with other persons. Can be transmitted in swimming pools (epidemic keratoconjunctivitis) and it is most common in midsummer to early fall.

Viral conjunctivitis

Autosomal dominant, congenital bleeding disorder MC congenital coagulopathy Six major types - characterized by deficient or defective vWF - Type I accounts for 75% to 80% of cases.

Von Willebrand Disease

Clinical features: Bleeding occurs in nasal, sinus, vaginal, and GI mucous membrane Spontaneous hemarthrosis and soft-tissue bleeds are less common than in hemophilia A. Common cause of menorrhagia. Bleeding is exacerbated by aspirin or NSAIDs Bleeding decreases with use of estrogen or pregnancy.

Von Willebrand Disease

Lab findings Pt normal Increased PTT Abnormal PFA (platelet function analysis) Normal platelet count

Von Willebrand Disease

Treatment Type 1 - Desmopressin acetate (DDAVP nasal spray) for bleeding prevention prior to procedures Factor VIII concentrates are preferred if factor replacement is necessary.

Von Willebrand Disease

usually congenital sounds like aortic stenosis

pulmonic stenosis

5 P's of Lichen Planus

purple papule polygonal pruritus planar

Normal bowel function

ranges from three stools/day to three stools/week

Icterus or jaundice, which is a yellowing of the sclera, is caused by what?

retention of bilirubin

which drug can turn bodily fluids orange/red?

rifampin

which abx causes Red Lobster Syndrome?

rifampin (Rifampin the Red lobster)

what are the 2 main organisms treated with PCN in primary care?

s. pyogenes (group A strep) and t. pallidum (syphilis)

Tinea Versicolor tx

selenium sulfide for 10 mins

when would you use clindamycin for strep throat or a skin/soft tissue infection?

serious PCN allergy

which class of abx causes Yellow Babies by displacing bilirubin?

sulfonamides (Bactrim/Septra)

Atypical Mycobacterial infections in children are most frequently located where?

superior anterior cervical or in submandibular nodes

what is the generic name for Lamisil?

terbinafine

when prescribing oral terbinafine, what labs would you order and when?

terbinafine is hepatotoxic. order baseline LFTs and then periodically while taking the med

which class of abx causes teeth discoloration and is contraindicated in children <8yo?

tetracylines

Lichen Planus tx

topical steroids

seen in IV drug users blowing murmur

tricuspid regurgitation

patients with sulfa allergies should not get what abx?

trimethoprim/sulfamethoxazole

what is the treatment of PCP pneumonia?

trimethoprim/sulfamethoxazole

which abx can cause hemolytic anemia in G6PD deficient patients?

trimethoprim/sulfamethoxazole

Posterior epistaxis occurs where?

Woodruff plexus

What happens to the pain of a gastric ulcer with food?

Worsens

what is the main use of ciprofloxacin?

abdominopelvic infections

Neutropenia

absolute neutrophil count (ANC) < 100

what are the anti-herpetic antivirals?

acyclovir, valacyclovir, famciclovir

Pubic Hair Tanner Staging 4

adult pattern of hair, smaller area

Diagnosis should specify panic disorder with or without ___________ (extensive avoidance of settings in which panic attacks have occurred).

agoraphobia

Male Genitals Tanner Staging 4

continued enlargement of testes, penis, enlarged glans

which class of abx can cause acute tubular necrosis (ATN)?

aminoglycosides (esp. gentamicin)

which class of abx is known for causing permanent SNHL?

aminoglycosides (esp. gentamicin)

which abx would you use for endocarditis prophylaxis prior to a dental procedure?

amoxicillin

which abx would you use to treat Lyme Disease in a child under 8 y/o?

amoxicillin

if you treated a sinus infection or otitis media with amoxicillin and the patient did not get better, which abx would you use next?

amoxicillin/clavulanate (augmentin)

which abx would you use as prophylaxis or to treat an animal or human bite?

amoxicillin/clavulanate (augmentin)

which antifungal is used for deep fungal infections (Cryptococcus, blastomycosis, etc)?

amphotericin B

which antimicrobial is the most nephrotoxic?

amphotericin B

which abx is associated with a diffuse, maculopapular, nonurticarial rash when given to someone with EBV?

ampicillin

What produces growth hormone?

anterior pituitary under stimulation from GHRH and suppression of somatostatin

Radiates to LSB/apex and leaning forward

aortic regurgatiion

Early diastolic Blowing murmur

aortic regurgitation

heard at pulmonic valve

aortic regurgitation

what are the major SE of flouroquinolones?

arthropathy and tendonopathy

what antibiotic would you use to treat chlamydia (non-gonoccocal urethritis/cervicitis)?

azithromycin

Mycobacterium avium complex (MAC) prophylaxis for HIV patients with CD4 < 50

azithromycin or clarithromycin

what are the macrolide abx?

azithromycin, clarithromycin, erythromycin

craniopharyngioma

benign tumor of the pituitary gland

the anti-influenza medication Zanamavir is associated with what side effect?

bronchospasm

what are the most common 1st generation cephalosporins?

cefazolin (IV) and cephalexin (PO)

which antibiotic would you use for perioperative prophylaxis?

cefazolin (ancef)

what is the silver standard (2nd line) IV anti-MSSA abx?

cefazolin (ancef); which is a 1st gen cephalosporin and is used in perioperative prophylaxis

what are the oral 3rd generation cephalosporins?

cefpodoxime (vantin) and cefdinir (omnicef)

what is the 5th generation cephalosporin?

ceftaroline

what is the only cephalosporin with MRSA coverage?

ceftaroline

what are the 4th generation cephalosporins?

ceftazidime and cefepime

what is the DOC for gonorrhea?

ceftriaxone

what is the parenteral/injectable 3rd gen cephalosporin?

ceftriaxone

which cephalosporin is used for meningitis?

ceftriaxone

what are the 2nd generation "respiratory" cephalosporins?

cefuroxime

what is the silver standard (2nd line) oral anti-MSSA drug?

cephalexin (Keflex)

if someone gets a rash from penicillin, you wouldn't give them a penicillin, but you could potentially give what class?

cephalosporin

if someone has an anaphylactic reaction to PCN, you wouldn't give a PCN or what other class?

cephalosporin

which class of abx are very similar to penicillins with regard to mechanism of action and allergic reactions?

cephalosporins

what is the non-respiratory flouroquinolone?

ciprofloxacin

what are the 2 most common anti-pseudomonal abx?

ciprofloxacin and levofloxacin

Mycobacterium avium complex (MAC) tx

clarithromycin + ethambutol for at least 12 months

what is the gold standard oral anti-MSSA drug?

dicloxacillin

which oral antibiotic would you use for a skin abscess in which s. aureus is the suspected organism?

dicloxacillin

Male Genitals Tanner Staging 2

enlargement of testes and scrotum, reddening

which drug can cause red-green color blindness? and what is the actual cause of the blindness?

ethambutol; optic neuritis

metronidazole is pregnancy category B, except when?

first trimester...fetotoxic

which class of abx are associated with tendon ruptures, esp Achilles tendon?

flouroquinolones

which antifungal medication is used to treat vaginal or esophageal candidiasis?

fluconazole

which antifungal medication would you give an adult with oral candidiasis?

fluconazole

Contact lenses use = pseudomonas tx= ??

fluoroquinolone (ciprofloxacin / Ciloxan drops)

Male Genitals Tanner Staging 5

full adult size and proportions (~age 15)

Kussmaul breathing

gasping, labored breathing, also called air hunger

what are the aminoglycoside abx?

gentamicin and tobramycin

Anti-HBc

had/have infeciton

HBeAg

highly infectious

Anti-HBs

immune

what can be done to limit the risk of Red Man Syndrome when giving vancomycin?

infuse over 60 minutes

what is the MOA of the flouroquinolones?

inhibit bacterial DNA topoisomerases

what is the MOA of cephalosporins?

inhibit cell wall synthesis

what is the MOA of PCN?

inhibits cell wall synthesis

what is the MOA of trimethoprim & sulfamethoxazole?

inhibits folate synthesis

what is the MOA of tetracyclines?

inhibits the 30S bacterial ribosome

what is the MOA of the aminoglycoside abx class?

inhibits the 30S bacterial ribosome

What is the MOA of macrolide abx?

inhibits the 50S bacterial ribosome

what is the MOA of lincosamide abx?

inhibits the 50S bacterial ribosome

what is the silver standard (2nd line) anti-aerobic abx?

clindamycin

which abx is most commonly associated with C. Diff?

clindamycin

flouroquinolones are contraindicated in what population?

kids under 18

Severe thrombocytopenia (spontaneous bleeding can occur)

less than 50,000 platelets

what are the respiratory flouroquinolones?

levofloxacin and moxifloxacin

what are the 3 best oral abx for MRSA infections?

linezolid (Zyvox), Doxy, TMP-SMX

what are the major ADRs of metronidazole?

metallic taste at high doses, disulfiram-like reactions, fetotoxic in first trimester (cat B after that)

What is the treatment for bacterial vaginosis?

metronidazole

what is a good abx for anaerobic infections below the diaphragm?

metronidazole

what is the nitroimidazole abx?

metronidazole

what is the treatment for giardiasis?

metronidazole

what is the treatment for mild C. Diff infections?

metronidazole

what is the treatment for mild c. diff?

metronidazole

what is the treatment for trichomoniasis?

metronidazole

which antibiotic is known for causing a disulfuram-like reaction?

metronidazole (drinking a beer on the metro (subway))

what 2 drugs are considered the gold standard anti-aerobic abx?

metronidazole or augmentin

what is a topical anti-fungal commonly used to treat vaginal candida infections?

miconazole (monistat)

which antibiotic can cause transient (not permanent) vestibular dysfunction (SNHL)?

minocycline

Heard at apex

mitral regurgitation

Holo/pansystolic blowing murmur

mitral regurgitation

Radiates to left axilla

mitral regurgitation

Has an opening snap

mitral stenosis

Heard best with bell in LLR position at apex

mitral stenosis

low pitch mid diastolic rumbling

mitral stenosis

seen in rheumatic fever

mitral stenosis

heard at apex and can turn into mitral regurgitation

mitral valve prolapse

late systolic murmur with mid systolic click

mitral valve prolapse

what are the anti-staph penicillins?

nafcillin (IV) and dicloxacillin (PO) Naf rhymes with staph. He had a staph infxn on his DICk

what is the gold standard IV anti-MSSA abx?

nafcillin (naf rhymes with staph)

IgG

not acute

which antifungal medication would you give a child with oral candidiasis (thrush)?

nystatin S&S (swish and swallow)

HBsAg

ongoing infection

terbinafine is typically used to treat what?

onychomycosis and cutaneous dermatophyte infections

what are the major ADRs of aminoglycosides?

ototoxicity and nephrotoxicity

Male Genitals Tanner Staging 3

penis begins to enlarge in length, then diameter

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

Clinical features: Sudden onset of severe unilateral pain and scrotal swelling Testis is painful to palpation Testicle and scrotum are edematous No relief with elevation of the testicle (negative Prehn sign).

Testicular Torsion

Diagnostic studies: Clinical diagnosis. If the diagnosis is equivocal, do not wait for laboratory studies. Doppler ultrasonography - decreased blood flow to the affected spermatic cord and testis. Radioisotope scan - decreased uptake in the affected testes.

Testicular Torsion

Testis is abnormally twisted on its spermatic cord Compromising arterial supply and venous drainage of the testis, leading to testicular ischemia. MC in prepubertal and postpubertal young males (12 to 18 years of age) Especially with a history of cryptorchidism (late descent of the testes).

Testicular Torsion

Treatment: Mild analgesics may be administered once the diagnosis is made This is a surgical emergency. Manual detorsion - may be attempted by experienced clinicians - whether this is successful or not, surgery will be required. Definitive treatment = Surgical detorsion with orchiopexy Emergent surgical intervention on the affected testis must be followed by elective surgery (orchiopexy) on the contralateral testis, which is also at risk

Testicular Torsion

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 blue on 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 heart and decreased pulmonary vascular markings

Tetralogy of Fallot

Chest radiograph: Boot shaped heart

Tetralogy of Fallot

Crescendo-decrescendo holosystolic at LSB, radiating to back Cyanosis Clubbing Increased RV impulse at LLSB Loud S2 Polycythemia usually present Tet (hypercyanotic) spells: - extreme cyanosis - hyperpnea - agitation - a medical emergency

Tetralogy of Fallot

Cyanotic Presentation: - Difficult feeding - Failure to thrive - "Tet spells" = a baby with cyanosis and loss of consciousness with crying

Tetralogy of Fallot

Microcytic Anemia Target cells ↑/Normal Iron ↑/Normal TIBC 30-100% Saturation ↑/Normal Ferritin Abnormal Hemoglobin electrophoresis ↑ Indirect bilirubin LDHterm-23

Thalassemia

Microcytic anemias (TICS)

Thalassemias Iron deficiency Chronic Sideroblastic

AKA full-thickness burns Involve and destroy the epidermis and the dermis including the dermal appendages. Skin has white, leathery, or charred appearance Skin non tender

Third Degree Burns

Breast Tanner Staging 1

pre-pubertal

Male Genitals Tanner Staging 1

pre-pubertal

Pubic Hair Tanner Staging 1

pre-pubertal

what is the bronze standard (3rd line) IV anti-MSSA abx?

vancomycin

what is the gold standard IV MRSA drug?

vancomycin

what is the treatment of mod-severe c. diff?

vancomycin

be careful of Bactrim/septra in people taking what medication?

warfarin (get an INR)

As generations of abx increase what happens to coverage?

you lose gram pos coverage and gain gram neg coverage

Patients may have mild symptoms or none - thalassemia trait [two normal α-chains] - carriers [three normal α-chains] Patients are often diagnosed after a nonresponse to treatment for a suspected iron deficiency or a normal ferritin level with a microcytic anemia. Patients with one α-globin chain (instead of the normal four) have Hgb H disease which is variably symptomatic When all four chains are deleted, stillbirth occurs from hydrops fetalis.

α-Thalassemia

AKA Cooley anemia

β-Thalassemia major

Symptoms begin by 4 to 6 months of age - when the switch from fetal hemoglobin (Hgb F) to adult hemoglobin (Hgb A) occurs Manifestations: - severe anemia - growth retardation - abnormal facial structure - pathologic fractures, osteopenia - bone deformities - hepatosplenomegaly and jaundice Tx: iron chelation and allogeneic stem cell transplantation

β-Thalassemia major

Major complication of thyroidectomy

Recurrent laryngeal nerve damage (hoarseness)

Increased urinary excretion of glucose SE: UTI, DKA, fractures

SGLT2 Inhibitor

Hashimoto's labs

Antithyroid peroxidase Antithyroglobulin antibodies

Inhibits degradation of GLP 1 to create more circulating GLP 1

DPP-4 Inhibitors

Sitagliptin (Januvia) Saxagliptin

DPP-4 Inhibitors

therapy that should be considered for all SS and S β0 thalassemia patients as young as 1 year old to increase Hgb F production, prevent complications, and increase lifespan.

Daily lifelong oral hydroxyurea

Localized urticaria appearing where the skin is rubbed (histamine release)

Darier's Sign

Severe and paroxysmal crying in the late afternoon to evening Unexplained paroxysms of irritability, fussing, crying that may develop into agonized screaming, an infant may draw up knees against the abdomen Peaks 2-3 months, ends around 4 months Very common, cause unknown

Colic

measured total calcium + [0.8 × (4 − albumin)]

Corrected calcium

4 C's of Measles (Rubeola)

Cough Coryza Conjunctivitis Cephalocaudal spread

what are the 2nd generation cephalosporins typically used for?

URTIs and soft tissue infections

what are the oral 3rd gen cephalosporins used for?

URTIs and soft tissue infections (similar indications as 2nd gen)

Born small Microcephaly Long and smooth philtrum Thin upper lip Small palpebral fissures Small distal phalanges

Fetal Alcohol Syndrome

Rolls over Sits leaning forward on arms Reaches for objects Raking grasp Responds to own name Holds own bottle Imitates speech sounds Vocal imitation

6-8 months

If the affected testicle in testicular torsion is corrected within a ________ timeframe, there is a greater chance of salvaging the testicle.

6-hour

Patients are hospitalized when the levels are above what?

70

Stands while holding on Passes object from hand to hand Feeds self Imitates waving Understands no May say mama

9-11 months

Treatment goal of finger stick blood glucose monitoring

< 130 fasting < 180 postprandial

Treatment goal A1C

< 7

Diabetes fasting glucose

> 126 (2 separate times)

Diabetes oral glucose tolerance test

> 200

Diabetes random glucose test

> 200 + diabetes symptoms

Diabetes A1C

> 6.5

Acute Hepatitis Fecal oral transmission Self limited

A E

This refers to premature fusion of one or more sutures (sagittal is most common). Referral to a neurologist is necessary to ensure proper growth and development

Craniosynostosis

Most common type of epistaxis

Anterior Epistaxis

Treatment: Direct pressure to the affected area Pt in sitting position while leaning forward Compress nares for about 15 minutes If bleeding continues locate site of bleeding Anesthetic vasoconstrictors - Topical decongestant (Oxymetazoline) - Topical Anesthetics (Lidocaine) - Cocaine Cautery of visible bleeding source Anterior packing last resort

Anterior Epistaxis

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

Clinical Features: Intermittent occurrence of cough, chest tightness, breathlessness, and wheezing One-third of children have no wheeze Classified according to the frequency of symptoms

Asthma

Diagnosis: Spirometry shows decreased FEV1/FVC ratio + > 12% increase in FEV1 after bronchodilator therapy ABG show hypoxemia and hypercapnia in severe cases Methacholine challenge test (bronchial provocation test) - If spirometry nondiagnostic - FEV1 decrease of more than 20%

Asthma

Obstruction of airflow Bronchial hyperreactivity Inflammation of the airway Disease of chronic inflammation leading to airway narrowing and increased mucus production

Asthma

Pharmacological Treament 1. SABA prn 2. Low dose ICS 3. Low dose ICS + LABA or medium dose ICS 4. Medium dose ICS + LABA 5. High dose ICS + LABA and omalizumab for allergies pts 6. High dose ICS + LABA + oral corticosteroids and consider omalizumab for allergy pts

Asthma

Atopic Triad

Asthma Eczema Seasonal rhinitis

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

Astrocytoma

DX: Diagnosis is based on MRI and histologic evaluation of biopsy TX: - Combination of surgical resection, radiation therapy, and chemotherapy - Have the best posterior fossa tumor prognosis

Astrocytoma

Most common PRIMARY childhood CNS tumors that develop from astrocytes

Astrocytoma

Symptoms Increased intracranial pressure (eg, morning headaches, vomiting, lethargy) Often benign Location of the tumor determines other symptoms and signs, for example - Cerebellum: Weakness, tremor, and ataxia - Visual pathway: Visual loss, proptosis, or nystagmus - Spinal cord: Pain, weakness, and gait disturbance

Astrocytoma

Treatment: Maintenance: - Chest physiotherapy - High-fat diet - Supplement fat-soluble vitamins (A, D, E, K) Acute exacerbations: - Antibiotics (colistin, tobramycin)

Cystic Fibrosis

Clinical features Acute onset of purulent discharge from both eyes. Mild decrease in visual acuity and mild discomfort. The eyes may be "glued" shut on awakening. Neisseria - copious purulent discharge. It is commonly unilateral. Chlamydia - a mucopurulent discharge with a marked follicular response on the inner lids - Nontender preauricular adenopathy is common

Bacterial Conjunctivitis

Common pathogens include - S. pneumoniae - S. aureus - Moraxella sp. Transmission is via direct contact Autoinoculation, from one eye to the other, usually via the fingers, is typical. The natural history of an infection caused by these common pathogens usually is self-limiting, but a secondary keratitis can develop. Rare pathogens include Chlamydia trachomatis and Neisseria gonorrhoeae.

Bacterial Conjunctivitis

Treatment: 1. Gentamicin/tobramycin (Tobrex) 2. Erythromycin ointment 3. Trimethoprim and polymyxin B (Polytrim)

Bacterial Conjunctivitis

CSF Analysis: Turbid to grossly purulent color Elevated pressure Elevated WBC, increased neutrophils Elevated protein Decreased glucose

Bacterial Meningitis

Clinical features: Altered mental status Fever Headache Vomiting Stiff neck Petechial rash is characteristic of N. meningitidis. Symptoms are acute, with patients presenting within hours or 1 to 2 days of infection. Soft-tissue abscess Otitis Kernig and Brudzinski signs Bacterial Meningitis

Bacterial Meningitis

Symptoms are based on three processes: - inflammation - increased intracranial pressure - tissue necrosis Primary causes today: - Streptococcus pneumoniae - Neisseria meningitidis - Group B streptococci. MC in neonates: Group B strep

Bacterial Meningitis

Treatment Antibiotic treatment is begun immediately if the CSF is not clear and colorless. Antibiotics should not be delayed if the LP cannot be accomplished or if imaging is necessary. The initial choice of antibiotic is based empirically on the patient's age and the most likely pathogen. Repeat LP and CSF analysis are crucial to assess response to treatment - CSF should be sterile after 24 hours. - decrease in pleocytosis and the proportion of neutrophils should be seen within 3 days.

Bacterial Meningitis

Dx: - patchy, segmental lobar, multilobar consolidation - Blood cultures x 2 - sputum gram stain Tx: - outpatient = doxy, macrolides - inpatient = ceftriaxone + azithromycin/respiratory FQs

Bacterial Pneumonia

Long-term complications - Marginal, anastomotic, and stomal ulcers present as abdominal pain, nausea, and vomiting - Postoperative ventral hernia is more common in open procedures. - Vitamin and mineral deficiencies (B12, Ca+, D) - Dehydration due to the small size of the gastric pouch - Noninsulinoma pancreatogenous hypoglycemia syndrome For the first 3 months after the procedure, patients may complain of nonspecific symptoms including body aches, dry skin, and hair loss or thinning.

Bariatric surgery

Short-term complications: - pneumonia - desaturation from obstructive sleep apnea or hypoventilation syndrome - DVT - anastomotic leaks associated with unexplained tachycardia and increasing oxygen requirements - bleeding from the anastomosis leading to unexplained tachycardia, hypotension, and desaturation

Bariatric surgery

Types: - gastric bypass surgery - laparoscopic adjustable gastric banding (LAP-BAND) - gastric sleeve - biliopancreatic diversion All the patients should be closely monitored for at least 24 hours after the procedure. - Particular attention should be paid to blood pressure, heart rate, and oxygen saturation.

Bariatric surgery

Adducting the hip while holding the knee straight, and when this pops the femoral head out of the socket, this raises suspicion of hip dysplasia

Barlow maneuver

Breast Tanner Staging 2

Breast bud

Fluid accumulation under the scalp secondary to birth trauma. Swelling is palpable crossing the midline.

Caput succedaneum

Immunocompetent children and adults aged 1 month to 50 years with bacterial meningitis tx

Cefotaxime or Ceftriaxone PLUS Vancomycin

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

Type of bronchiectasis (permanent dilatation of bronchi and destruction of bronchial walls) An autosomal recessive mutation in the CFTR gene

Cystic Fibrosis

Increase in incidence in adults older than 60 years of age Can present within the central metaphyseal area

Chondrosarcoma

Diagnostic studies: SMUDGE CELLS on peripheral smear Mature lymphocytes (isolated lymphocytosis with leukocytosis > 20,000) Treatment - observation - lymphocytes are > 100,000 - symptomatic, treat with chemotherapy

Chronic Lymphocytic Leukemia (CLL)

Middle age patient Often asymptomatic (seen on blood tests) Fatigue Lymphadenopathy Splenomegaly Population: - Adults - most common form of leukemia in adults - peak age 50 y/o

Chronic Lymphocytic Leukemia (CLL)

SMUDGE CELLS on peripheral smear, mature lymphocytes

Chronic Lymphocytic Leukemia (CLL)

Diagnostic studies: Philadelphia chromosome (translocation of chromosome 9 and 22) - BCR ABL gene - "Philadelphia CreaM cheese", splenomegaly Tx: tyrosine kinase inhibitors (imatinib, nilotinib) and allogeneic bone marrow transplantation

Chronic Myeloid Leukemia (CML)

Philadelphia chromosome (translocation of chromosome 9 and 22

Chronic Myeloid Leukemia (CML)

Strikingly Increased WBC count > 100,000 Hyperuricemia Population: - Adults - patient usually > 50 y/o 70% asymptomatic until the patient has a blastic crisis

Chronic Myeloid Leukemia (CML)

If perforated membrane or chance of perforation what tx?

Ciprofloxacin + Dexamethasone OR Ofloxacin

what is the lincosamide abx?

Clindamycin

Treatment Oral replacement (1 mg/day) with folic acid is first-line treatment. Avoid alcohol and folic acid metabolism antagonists (e.g., trimethoprim, seizure medications).

Folate Deficiency

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 pulses with 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" and angiography

Coarctation of the Aorta

Diagnosis: 1st Echocardiogram EKG = LVH CXR = rib notching "figure of 3 sign"

Coarctation of the Aorta

Involves narrowing in the proximal thoracic aorta Noncyanotic Defects

Coarctation of the Aorta

Systolic, LUSB and left interscapular area Infants may present with CHF Older children may have systolic hypertension or murmur or underdeveloped lower extremities Differences between arterial pulses and blood pressure in UE and LE pathognomonic

Coarctation of the Aorta

Treatment: Prostaglandins E1 Generally, require surgical repair with dilating the segment with balloons

Coarctation of the Aorta

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 with intractable 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

Diagnosis: Rule of 3's ⇒ cry > 3 hrs/day, 3 d/wk, for 3 weeks Complete history Physical Exam: r/o pathology

Colic

Clinical Features: 1-10 day history Cough Purulent sputum SOB Tachycardia Pleuritic chest pain Fever/chills Crackles Dullness to percussion if effusion Bronchial breath sounds over area of consolidation

Community Acquired Pneumonia

Common Causes: Streptococcus pneumoniae (pneumococcus) Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Klebsiella pneumoniae

Community Acquired Pneumonia

Diagnosis: Sputum stain or culture (MC pathogen is strep pneumoniae) CXR: - lobar or segmental infiltrated - air bronchograms - pleural effusion Elevated WBC Elevated procalcitonin indicated bacterial

Community Acquired Pneumonia

Management: Free of respiratory distress = outpatient with oral antibiotics Hospitalization if: - neutropenia - involvement of more than one lobe - altered mental status If inpatient: treat with antibiotics for a minimum of 5 days or until clinically stable and afebrile for at least 48-72 hours

Community Acquired Pneumonia

Considered a precursor to antisocial personality disorder in adulthood. High comorbidity with ADD and ADHD, learning disability, mood disorders, and substance abuse disorder.

Conduct disorder

Diagnostic criteria: Established on the basis of a pattern of behavior that involves violation of the basic rights of others or of social norms, with at least three acts of the following types: - aggression toward people and animals - destruction of property - deceitfulness or theft - serious violations of rules

Conduct disorder

Treatment: Environmental and behavioral modifications and family therapy Sometimes used to reduce aggressive/assaultive behaviors - Stimulants (dextroamphetamine, methylphenidate) - Bupropion - Clonidine - Lithium - Haloperidol - Valproic acid The SSRIs may aid therapy by reducing impulsivity and mood lability/irritability.

Conduct disorder

Caused by impaired sound transmission to the inner ear. Blockage/obstruction caused by cerumen impaction or exudate from otitis externa Otitis media with effusion Otosclerosis (abnormal bony growth of the middle ear) Ear trauma/injury

Conductive Hearing Loss

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

AKA acute viral laryngotracheobronchitis MC in 6 months to 5 years Causes: - MC = parainfluenza virus types 1 and 2 - RSV - adenovirus - influenza - rhinovirus

Croup

Clinical findings: Harsh, barking, seal-like cough inspiratory stridor Hoarseness Aphonia Low-grade fever Rhinorrhea

Croup

Diagnostic studies: Diagnosis is usually made clinically with characteristic findings on history and physical examination. Posteroanterior (PA) neck film may show subglottic narrowing (Steeple sign). The lateral neck film will differentiate this from epiglottitis (thumbprint)

Croup

Management: Mild - does not usually require treatment as it is self-limited - Patients should stay well hydrated Corticosteroids Humidified air or oxygen Nebulized epinephrine Hospitalization may be required for patients with severe symptoms

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

Diagnosis: - Ultrasound may be helpful in identifying undescended testicles in abdominal space Treatment: - Treat with surgery (orchiopexy) by age 1 - Current recommendation is to correct as soon as possible after 4 months of age

Cryptorchidism

Failure of testes to descend (one or both) Rare in full-term babies Common in baby boys born prematurely (30%) If not repaired risks infertility and malignancy

Cryptorchidism

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

Abnormally thick mucus Difficulty clearing mucus Recurrent respiratory infections (especially pseudomonas) Steatorrhea

Cystic Fibrosis

Diagnosis: Quantitative sweat chloride test CXR may reveal: - hyperinflation - mucus plugging - focal atelectasis

Cystic Fibrosis

Normal glucose until 2-8 am when it rises. Results from decreased insulin sensitivity and a nightly surge of counter-regulatory hormones during nighttime fasting Treatment: - bedtime injection of NPH to blunt morning hyperglycemia - avoiding carbohydrate snack late at night

Dawn Phenomenon

what is the MOA of nitroimidazole abx?

DNA damage

Signs/Symptoms: Abdominal pain Fecal mass Dilated rectum packed with stool Urinary frequency Goal ⇒ daily, soft stools without pain every 1-2 days without incontinence DX: rectal exam, KUB

Encopresis

Treatment: Acute Treatment - Peg/MiraLAX - Glycerin suppository for infants up to 3d Chronic Treatment - Elimination of all cow's milk 1-2 wk. trial - Maintenance laxatives for 6 mo-1 yr. - High fiber diet and increase fluids - Toilet sitting same time 5-10 min after meals

Encopresis

The primary defect involves collagen and connective tissue, resulting in joint laxity, hyperelastic skin, pectus deformity, and excessive bruising. Death often results from ruptured aneurysm.

Ehlers-Danlos syndrome

Pneumonia MC in postsplenectomy

Encapsulated organisms Streptococcus pneumoniae Haemophilus pneumoniae

The most common primary benign bone neoplasm of the hand and is asymptomatic unless complicated by pathologic fracture

Enchondroma (cartilaginous tumor)

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

Almost always associated with severe constipation: liquid stool leaks around a hard, retained stool mass and is involuntarily released through the distended anorectal canal Cause: - Functional: chronic constipation - Emotional: school, divorce, etc.

Encopresis

Fecal incontinence Refers to the repetitive, voluntary or involuntary, passage of stool in inappropriate places by children four years of age and older, at which time a child may be reasonably expected to have completed toilet training and exercise bowel control. MC in males

Encopresis

Breast Tanner Staging 3

Enlargement/elevation of breast and areola

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

Diagnosis: First tested with a urinalysis and urine culture to rule out infection Thorough history and physical with fluid intake, stool, and voiding diary should be compiled in order to investigate abnormal patterns seen in conditions like constipation or diabetes insipidus

Enuresis

Involuntary loss of urine in a child older than 5 years Clinically significant = occurs > two times per week for > three consecutive months or affects day-to-day life Primary: - patients who have never successfully maintained a dry period - due to delayed maturational control or inadequate levels of ADH secretion during sleep Secondary enuretics: - dry for several months before regular wetting occurs

Enuresis

Treatment: Patients younger than 5 years of age do not require investigation or treatment Behavioral modification: - Nighttime audio alarm that sounds as soon as the child starts to urinate, eventually conditioning controlled bladder emptying Medications: - Desmopressin acetate (DDAVP) acts to concentrate the urine. If given in the evening, less urine is produced overnight, decreasing the likelihood of wetting With all therapies, the cure rate is 15% per year after the age of 5 Children who remain enuretic past age 8 have a 10% risk of never resolving their symptoms

Enuresis

Apparent before the second year of life that manifests as a deceleration in height. Height is hereditary and closely matches the parental height. Physical examination: The child has normal development without other signs or symptoms of disease.

Familial short stature

Special testing: It is rare that additional workup is necessary. Further testing to rule out other causes may include: - CBC - ESR - urinalysis - BUN and creatinine - serum electrolytes, including calcium and phosphorus - examination of stool for fat content - karyotype - intrinsic growth factor (IGF)-1 and IGF-binding protein 3 Radiography of the distal radius reveals bone age equal to chronological age. Treatment: Reassure parents that deceleration is normal and expected, especially if both parents are short.

Familial short stature

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 Seizures

Convulsion associated with an elevated temperature greater than 38° (100.4 F) Most common seizure in infants and young children MC between 6 months and 5 years of age Slight male predominance Associated with fever (≥ 38°C) without evidence of CNS infection, afebrile seizure history, or metabolic disturbance

Febrile Seizures

Diagnosis: Clinical diagnosis Consider lumbar puncture if suspicious of meningitis - lack of HiB or s. pneumoniae vaccination Physical exam suggesting meningitis or some CNS infection

Febrile Seizures

Risk factors: Elevated fever (≥ 38°C) Age - potentially due to developing nervous system being vulnerable to fever Viral infection (i.e., HHV-6, Influenza virus) Family history - potential genetic component Recent immunizations - the absolute risk is small

Febrile Seizures

Treatment: Mostly counseling, reassurance, and educating the parent Antipyretics help alleviate symptoms of fever Consider obtaining EEG though not required May treat with benzodiazepine if lasts >5 minutes Terminate status epilepticus with benzo or phenytoin Initiate status epilepticus protocol if continues Rarely develops into epilepsy Monitor complex febrile seizures as more likely to recur

Febrile Seizures

What is the MC cause of appendicitis

Fecalith (hardened fecal matter)

Average start of breast development ~10.5 years Followed closely by pubic/axillary hair and growth spurt Menses start about 2 years after breast development starts (12.5 yr) Girls are typically Tanner 3-4 at menarche

Female Puberty

Classic triad of mononucleosis

Fever Lymphadenopathy Pharyngitis

Burn that involves minor damage to epidermis Characterized by erythema, tenderness, and the absence of blisters

First Degree Burns

Acute Otitis Media antibiotics

First line: Amoxicillin Allergy: Cephalosporin, TMP/SMX, azithromycin

Pharyngitis antibiotics

First line: Penicillin or Cefuroxime Allergy: Erythromycin or other macrolide

Anterior: Closes around 10 to 26 months of age Posterior: Closes around 1 to 3 months A third along the sagittal suture may be present and may be associated with trisomy 21.

Fontanelles

Outpatient antibiotic for pneumonia patient who is otherwise healthy and without risk factors

Fluoroquinolone (levofloxacin)

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.

Focal Seizure

Obese patients Heroin use HIV+ black males. Primary, when no underlying cause is found Secondary, when an underlying cause is identified Familial forms Secondary to nephron loss and hyperfiltration, such as with chronic pyelonephritis and reflux, morbid obesity, diabetes mellitus

Focal segmental glomerulosclerosis (FSGS):

(consciousness impaired) Formerly called complex partial seizures Aura followed by impaired consciousness Automatisms (ie. Lip-smacking) Present with a postictal state (confusion and loss of memory) which differentiate them from absence seizures

Focal seizures with cognitive impairment

EEG reveals interictal spikes or spikes associated with slow waves in the temporal or frontotemporal areas

Focal seizures with cognitive impairment

(consciousness maintained) Formerly called simple partial seizures No alteration in consciousness. Abnormal movements or sensations Isolated activity of limb Transient altered sensory perception May spread to include the entire side of the body "Jacksonian march"

Focal seizures with retained awareness

MC cause poor dietary intake (alcoholics, anorexia, low fruit/veg intake) Other causes - defective absorption - pregnancy - chronic hemolytic anemias - alcohol abuse - Phenytoin, trimethoprim-sulfamethoxazole, sulfasalazine - malabsorption

Folate Deficiency

Normal Methylmalonic acid ↑ Homocysteine Sore tongue (glossitis) Macro-ovalocytes Hypersegmented polymorphonuclear cells Howell-Jolly bodies What macrocytic anemia?

Folate Deficiency

Increase insulin sensitivity in peripheral receptor site Contraindications: CHF, liver disease, fluid retention, weight gain

Thiazolidinediones

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

Foreign Body

Clinical features: Inspiratory stridor (if high in the airway) or wheezing and decreased breath sounds (if low in the airway) Asphyxia may result from the aspiration of obstructing material. Pneumonia may develop secondary to aspiration of toxic materials. Acute gastric aspiration is one of the most common causes of ARDS

Foreign Body Aspiration

Management Bronchoscopy may help to establish the diagnosis but can also be the treatment of choice for removal of the object. Cultures should be obtained if postobstructive pneumonia is suspected.

Foreign Body Aspiration

Unintentional inhalation of foreign body into the airway. MC in children <3 years and adults older than 50. Heimlich maneuver is lifesaving. The degree of injury depends on the substance aspirated. Most often food and can be life-threatening. 80% in mainstem or lobar bronchus right > left

Foreign Body Aspiration

Aggressive flushing can cause perforation of the tympanic membrane, so caution is advised while irrigating After each flush, it is prudent to recheck the external canal for retained foreign body (FB) fragments, which can occur with an insect Irrigation of the external ear can be uncomfortable for the child consider treating with topical pain agents such as benzocaine-anti-pyrene

Foreign body in ear

Insects must be immobilized prior to removal. Drown insects with mineral oil or viscous lidocaine before attempting removal Removal of foreign body which requires direct visualization prior to removal either via warm irrigation with a syringe, or instruments like an alligator forceps

Foreign body in ear

Burns that destroy the skin and subcutaneous tissue, with further involvement of fascia, muscle, bone, or other structures Extensive Nerve damage results in little to no sensation of pain

Fourth Degree Burns

Pale blue irises, long narrowed facies, large protruding ears, large protruding jaw, flat feet, and hyperextensible fingers Prepubertal large gonads Autism and/or moderate to severe intellectual disability with disorganized speech patterns Mitral valve prolapse Female carriers exhibit mild learning disabilities.

Fragile X syndrome

Occur when there is widespread seizure activity in the left and right hemispheres of the brain. Start midbrain or brainstem and spreads to both cortices Types - Absence seizures - Tonic-clonic seizures - Atonic seizures - Clonic seizures - Tonic seizures - Myoclonic seizures

Generalized Seizures

Characterized by persistent, excessive anxiety regarding general life events that lasts for 6 months or more. It is not situational (as in phobias) or episodic (like panic disorder). Often present to medical providers with somatic complaints, such as fatigue or muscle tension. Age of diagnosis is around 20 years, although patients typically report feeling anxious for as long as they can remember.

Generalized anxiety disorder

Diagnostic criteria: At least three of the following: - restlessness or hypervigilance - easy fatigability - irritability - sleep disturbance - muscle tension - difficulty concentrating. Medical disorders, such as thyroid dysfunction, stimulant abuse, alcohol withdrawal, caffeine intoxication, and cardiac arrhythmias, must be ruled out.

Generalized anxiety disorder

Treatment: First line: SSRIs, SNRIs, and buspirone Low-dose TCAs also may help but are not considered first line. Benzodiazepines can be used as an adjunct for short-term management of severe symptoms Behavioral and insight-oriented therapy also should be initiated.

Generalized anxiety disorder

5-year-old female is brought to the office by her mother because of "coke colored" urine for 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

Clinical features: Hematuria is present Urine is often tea or cola colored. Oliguria or anuria is present. Edema of the face and eyes is present in the morning Edema of the feet and ankles occurs in the afternoon and evening. Hypertension is also a common

Glomerulonephritis

Damage of the renal glomeruli by deposition of inflammatory proteins in the glomerular membranes as the result of an immunologic response. The severity of disease is dictated by the degree of glomerular injury. 60% of cases are in children 2 to 12 years of age. Prognosis is excellent in children and worse in adults, especially in those with preexisting renal disease.

Glomerulonephritis

Diagnostic studies: Urinalysis Serum complement (C3) levels are often decreased. Renal biopsy may be done to determine exact diagnosis or severity of disease if diagnosis remains in doubt.

Glomerulonephritis

Treatment: Steroids and immunosuppressive drugs may be used to control the inflammatory response, which is responsible for the damage Dietary management: Salt and fluid intake should be decreased. Dialysis should be performed if symptomatic azotemia is present. Medical therapy - ACEi if chronic

Glomerulonephritis

Two types: Nephritic - IgA Nephropathy (Berger disease) - Postinfectious - Membranoproliferative - Rapidly progressive Nephrotic - membranous - minimal change disease - focal segmental glomerulosclerosis (FSGS) - Secondary: lupus, diabetes, preeclampsia

Glomerulonephritis

Clinical features: Presentation is less acute; patients typically have symptoms for weeks to months. Subtle mental status changes are common.

Granulomatous Meningitis

Diagnostic studies: CSF analysis and culture is key, but results may take weeks depending on etiology. CT or MRI: - marked enhancement of the meninges - occasionally hydrocephalus. Serologic studies may help to confirm suspected etiologies. Treatment depends on cause.

Granulomatous Meningitis

Pathogens: - Mycobacterium tuberculosis - fungi (Cryptococcus, Coccidioides sp., Histoplasma) - spirochetes (Treponema pallidum, Borrelia burgdorferi). MC in immunocompromised individuals. Noninfectious cause = sarcoidosis

Granulomatous Meningitis

(+) anti-GBM antibodies Dx linear IgG deposits Treat with high dose steroids, plasmapheresis + cyclophosphamide

Goodpasture's syndrome

(+) C-ANCA

Granulomatosis with polyangiitis (Wegener's)

CSF Analysis: Variable Color Normal pressure Mildly elevated WBC count, lymphocytes Elevated protein Decreased glucose

Granulomatous Meningitis

Pioglitazone Rosiglitazone

Thiazolidinediones

MC cause of hyperthyroidism Autoimmune disease affecting TSH receptors Some antibodies act like TSH to cause secretion of thyroid hormone Diffuse symmetric, enlargement and goiter may be seen Associated with HLA markers Exophthalmos

Grave's disease

May be an isolated disorder or may occur as a result of other pituitary hormone deficiencies. Causes - MC idiopathic - Congenital (empty sella syndrome) - Acquired (craniopharyngioma) - Laron syndrome

Growth hormone (GH) deficiency

Physical examination: Decline in growth velocity or subnormal growth is characteristic. Children with dwarfism have distinctive facial features. Truncal obesity may be present, because GH also promotes lipolysis. Impaired peripheral vision with optic chiasm tumors is frequent. Delayed puberty and webbed neck are seen in cases of Turner syndrome Disproportionately short limbs compared with trunk suggest a skeletal dysplasia.

Growth hormone (GH) deficiency

Testing: Testing to rule out other causes as mentioned in failure to thrive. Radiography of the distal radius should be performed for bone age. In some cases, a trial of human GH may be warranted and may confirm the diagnosis.

Growth hormone (GH) deficiency

Treatment Human GH has been approved for specific causes, such as: - Prader-Willi syndrome - Turner syndrome - Children born small for gestational age who fail to grow - Chronic renal failure Referral to a pediatric endocrinologist is recommended

Growth hormone (GH) deficiency

Turner Syndrome Tx

Growth hormone therapy and sex hormone replacement therapy

Acute and Chronic Transmission: Sexual or sanguineous Risk of hepatocellular carcinoma The vaccine is given to all infants (birth, 1-2 mo, 6-18 mo)

Hepatitis B

Pneumonia MC in COPD

Haemophilus pneumoniae

Pubic Hair Tanner Staging 5

Hair covers entire pubic area, medial thighs (age 14-15)

2-year-old who is brought to the office by his mother. The child has had a low-grade fever, rash, and loss of appetite for the past two days. On physical exam, there are multiple 2-3-mm grey vesicular lesions on the bilateral palms and soles and several vesicles and ulcers on the oral mucosa. The physician assistant informs her parents that this disease typically resolves spontaneously and to keep the patient hydrated.

Hand-Foot-and-Mouth Disease

Cause: Coxsackievirus A16 Red papules or vesicles occur on the tongue, oral mucosa, hands, feet, and buttocks. Fever, sore throat, and malaise are usually mild. Treatment is supportive.

Hand-Foot-and-Mouth Disease

Children < 10 years old Caused by coxsackievirus type A virus Sores in the mouth Rash on the hands, feet, mouth, and buttocks The virus usually clears up on its own within 10 days Treatment is supportive, anti-inflammatories

Hand-foot-and-mouth disease

MC cause of hypothyroidism

Hashimoto's thyroiditis

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

Clinical features: Jaundice from elevated indirect bilirubin Bilirubin gallstones Bone marrow expansion visible on x-rays Sickle cell disease can cause delayed puberty. Hepatosplenomegaly may be the cause of RBC lysis. Petechiae and purpura may indicate thrombocytopenia caused by TTP; DIC; HUS; and HELLP syndrome

Hemolytic Anemia

Decreased RBC survival and increased cell lysis. Mnemonic HIT - Hereditary, Immune attack, and Trauma to the RBCs. Hereditary - intrinsic (problem within the RBC) - hereditary spherocytosis - G6PD deficiency - sickle cell syndromes. External to the erythrocyte - immune attack - trauma to RBCs caused by TTP, HUS, DIC, burns

Hemolytic Anemia

Diagnostic studies: Elevated corrected reticulocyte count Falling hemoglobin Elevated indirect bilirubin Elevated LDH Direct Coombs or direct antiglobulin test (DAT) - antibodies on the RBCs Indirect Coombs - antibodies in the patient's serum.

Hemolytic Anemia

Children Cause: E coli Normal PT/PTT Fever Bleeding and clotting disorder Renal failure Treatment - support - emergent plasma exchange - no platelets

Hemolytic Uremic Syndrome (HUS

Clinical features: Severely affected patients - repeated spontaneous hemorrhagic episodes with hemarthroses - epistaxis - intracranial bleeding - hematemesis - melena - microscopic hematuria - bleeding into the soft tissue and gingiva. Less severely affected patients - experience excessive bleeding following trauma or surgery PTT is prolonged. Reduced factor 8

Hemophilia A

General characteristics: Hereditary disease characterized by excessively prolonged coagulation time - X-linked recessive Most severe bleeding disorder

Hemophilia A

Treatment: First line: Infusion of recombinant factor VIII Mild-Moderate - Desmopressin (DDAVP) may elevate factor VIII Avoid aspirin Pain management - celecoxib - acetaminophen - opioids

Hemophilia A

Factor IX deficiency AKA Christmas disease Heterogeneous group of disorders X-linked recessive disorder affecting males

Hemophilia B

HIT assay (PF4 heparin antibody ELISA test) is positive PTT Abnormal Causes clotting Tx: Stop heparin and use another anticoagulant

Heparin Induced Thrombocytopenia

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

Acute - fatigue - malaise - nausea, vomiting - anorexi - fever - right upper quadrant pain Transmission: Fecal-oral Serum IgM anti-HAV Vaccine: killed (inactivated) - given in two doses, recommended for travelers.

Hepatitis 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 an absence of stool in the rectal vault. A contrast enema reveals dilated loops of bowel and megacolon.

Hirschsprung Disease

AKA congenital megacolon Caused by congenital absence of Meissner and Auerbach autonomic plexuses enervating the bowel wall. Symptoms may include constipation or obstipation, vomiting, and failure to thrive. Treatment is surgical resection of the affected bowel.

Hirschsprung Disease

At birth infants are asymptomatic First sign: baby's inability to pass meconium, 48 hours postpartum Other clinical features include: - constipation - vomiting - abdominal distension

Hirschsprung Disease

Caused by a lack of caudal migration of the ganglion cells from the neural crest It produces contraction of a distal segment of colon, causing obstruction with proximal dilatation. Absent plexuses (regulate bowel function) → Intestine muscles permanently constricted → Passing stool difficult, impossible

Hirschsprung Disease

Diagnosis: Rectal suction biopsy, revealing the absence or paucity of ganglion cells Barium assisted radiography Digital rectal exam

Hirschsprung Disease

Treatement: Resection of the affected segment or colostomy

Hirschsprung Disease

Clinical features: Painless cervical, supraclavicular, and mediastinal lymphadenopathy. Pain in the affected node after ingestion of alcohol may occur. Nodes on both sides of the diaphragm indicate stage III or above. A designation indicates a lack of constitutional symptoms. One-third of patients present with constitutional (stage B) symptoms (fever, night sweats, weight loss, pruritus, and fatigue), which are associated with a poorer prognosis.

Hodgkin's Lymphoma

Diagnostic studies: Lymph node biopsy Reed-Sternberg cells confirm the diagnosis Basic staging includes: - CT of neck, chest, abdomen, and pelvis - biopsy of the bone marrow

Hodgkin's Lymphoma

Group of cancers characterized by: - enlargement of lymphoid tissue, spleen, and liver - presence of Reed-Sternberg cells in lymph node biopsy tissue Epstein-Barr virus also appears to be an important factor MC in 15 and 45 years, peaking in the 20s, and again after 50 years of age Rare in children younger than 5 years of age.

Hodgkin's Lymphoma

Treatment: Combination chemotherapy cures most patients, even those with advanced-stage disease Low risk Stage IA and IIA - Radiation therapy Most other patients receive ABVD chemotherpay - Adriamycin - Bleomycin - Vinblastine - Dacarbazine

Hodgkin's Lymphoma

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 this.

Hydrocele

Clinical features: Soft, nontender fullness of the hemiscrotum that transilluminates Mass may wax and wane in size An indirect hernia may be concurrently present.

Hydrocele

Diagnostic studies: Urinalysis with microscopic analysis is negative. Ultrasonography is rarely indicated but can distinguish between hydrocele, spermatocele, and testicular tumors Treatment: elective repair as clinically indicated

Hydrocele

Mass of the fluid-filled congenital remnants of the tunica vaginalis Usually resulting from a patent processus vaginalis.

Hydrocele

Clinical features: Severity of symptoms depends on level Anorexia Nausea Constipation Polyuria Polydipsia Dehydration Change in level of consciousness (lethargy, stupor, and coma). (2)Signs of intravascular volume depletion (e.g., orthostatic hypotension and tachycardia) are frequent.

Hypercalcemia

Diagnostic studies: Serum calcium is high (level must be corrected for albumin levels) CXR may reveal an underlying pulmonary mass Perform urinalysis for hematuria, an early sign of RCC A 24-hour urine collection must be done for calcium determination. Erythrocyte sedimentation rate may be elevated in monoclonal gammopathy - Protein electrophoresis of serum or urine may be needed to confirm the dx

Hypercalcemia

MC disorder of calcium and phosphorous MC cause hospitalized patients with malignancy Other causes: - vitamin D intoxication - hyperparathyroidism - sarcoidosis

Hypercalcemia

Treatment: Isotonic saline (NS or LR) should be used for volume repletion Loop diuretics (Bumetanide/Furosemide) should be used if the patient is hypervolemic after volume repletion Severe - Bisphosphonates alone or in combination with calcitonin - Zoledronic acid

Hypercalcemia

45, X0 (monosomy X) Short webbed neck, no breast development High FSH Cyclic estrogen and progestins

Turner Syndrome

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 a prominent 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

34-year-old female complaining of irritability and nervousness, heat intolerance with increased sweating, and weight loss despite an increase in appetite.

Hyperthyroidism

Causes: - Graves - Toxic multinodular goiter - Hashimoto thyroiditis - Pituitary tumor - Pregnancy - Exogenous thyroid hormone - Excessive dietary iodine intake - Radiographic contrast - Amniodarone use

Hyperthyroidism

Symptoms: hair loss clammy skin soft nails exophthalmos tachycardia weight loss diarrhea heat intolerance muscle weakness, cramps sleep difficulties hyperreflexia fine tremor anxiety, nervousness oligomenorrhea or amenorrhea

Hyperthyroidism

Treatment: Propanolol to conotrol symptoms Methimazole Propylthiuracil Radioactive Iodine ablation Thyroidectomy

Hyperthyroidism

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

Causes - Hereditary syndromes - Chronic hypertension Symptoms - Dyspnea, chest pain, syncope Examination - Sustained PMI (point of maximal impulse) - S4 - Variable systolic murmur - Bisferiens carotid pulse

Hypertrophic Cardiomyopathy

Clinical Presentation: Patients most commonly present with dyspnea and angina. S Syncope and arrhythmias are common May be asymptomatic Sudden death may be the initial presentation Sustained PMI or triple apical impulse Loud S4 gallop Variable systolic murmur A bisferiens carotid pulse Jugular venous pulsations with a prominent "a" wave

Hypertrophic Cardiomyopathy

Diagnostic Studies: Chest radiography is often not remarkable. Echocardiography is the key to diagnosis - left ventricular hypertrophy - asymmetric septal hypertrophy - small left ventricle - diastolic dysfunction Myocardial perfusion studies, cardiac MRI, and cardiac catheterization can also be helpful.

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

Abnormal placement of the urethra where the meatus is proximal and ventral to its normal or anterior location (penis pointing downwards) Do not circumcise Bilateral renal ultrasonography is warranted to rule out ascending pathology. Refer to a pediatric urologist.

Hypospadias

28-year-old woman with increased fatigue and a 10-lb weight gain over the last 2 months. She states that she "feels cold" all the time, has decreased energy, and is experiencing worsening constipation. Patient has a tender thyroid, increased TSH, elevated antimicrosomal antibodies, and increased antithyroglobulin antibodies.

Hypothyroidism

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 height and 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

Etiology: Hashimoto's (chronic lymphocytic/autoimmune) Previous thyroidectomy/iodine ablation Congenital

Hypothyroidism

Labs: TSH- elevated in primary disease. Low T4 (↑ TSH and ↓ Free T4) Hashimoto's: Antithyroid peroxidase, antithyroglobulin antibodies

Hypothyroidism

Symptoms: Dry, coarse hair dry skin Myedema (non pitting fluid retention) brittle nails puffy face bradycardia weight gain constipation cold intolerance fatigue, lethargy muscle aches hyporeflexia memory loss depression heavy menstrual periods

Hypothyroidism

Treatment: Levothyroxine - replacement T4; T4 is converted to T3 - taken on an empty stomach Follow up with serial TSH monitoring every 4-6 weeks

Hypothyroidism

MC cause of acute glomerulonephritis worldwide Young males within days (24-48 hours) after URI or GI infection Caused by IgA immune complexes which are the first line of defense in respiratory and GI secretions so infections cause an overproduction which then damages the kidneys Diagnosed by (+) IgA deposits in mesangium and with immunostaining

IgA Nephropathy (Berger disease)

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 highly contagious skin infection that causes red sores on the face Form around the nose and mouth Sores rupture, ooze for a few days, then form a yellow-brown crust "honey-colored" and weeping Most commonly caused by S. aureus Complications: poststreptococcal glomerulonephritis

Impetigo

What happens to the pain of a duodenal ulcer with food?

Improves

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

Symptoms - nausea - bloating - flatulence - diarrhea - cramping - occasionally, vomiting. Easily managed by avoiding milk and dairy products or use of lactase enzyme tablets or drops.

Lactose Intolerance

Conductive hearing loss on Weber Test

Lateralization to the affected side

Sensorineural hearing loss on Weber Test

Lateralization to the unaffected side

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

DX: Diagnosis is based on MRI and histologic evaluation of biopsy TX: - Combination of surgery, radiation therapy, and chemotherapy - The long-term survival with treatment is about 70%

Medulloblastoma

Metastasize through CSF Bimodal peak at age 3-4 and at age 8-10 Patients present most commonly with: - nausea/vomiting - headache - visual changes (eg, double vision) - unsteady walking or clumsiness

Medulloblastoma

Most common MALIGNANT posterior fossa tumor in children R7epresents about 20% of all pediatric CNS cancers

Medulloblastoma

Repaglinide Nateglinide

Meglitinides

Stimulate pancreatic beta cell insulin release SE: hypoglycemia

Meglitinides

Due to SLE, viral hepatitis

Membranoproliferative glomerulonephritis

MC in non-diabetic adults associated with malignancies. Caused by immune complex formation in the glomerulus - basement membrane becomes damaged

Membranous nephropathy

Pneumonia MC in children <2 year

Parainfluenza virus

Most common source of bone lesions in those 60+

Metastatic Carcinoma

Decreases hepatic glucose production SE: - Lactic acidosis - GI - Kidney Benefits: weight loss, cheap

Metformin

What hyperthyroidism medicine should be taken after the first trimester of pregnancy?

Methimazole

(+) P-ANCA

Microscopic polyangiitis

Symptoms >2 days/week, not daily Nighttime symptoms 3-4x/month FEV1 >80% FEV1/FVC normal Minor limitation with daily activities What asthma classification?

Mild Persistent

Very small, white papules concentrated on nose, cheeks, forehead, and chin. Resolve without intervention in 1 to 2 months

Milia

A flushed macular appearance frequently involving neck, face, scalp, and diaper area; it is caused by blockage of eccrine sweat glands. Light clothing and decreased humidity speed resolution of this "prickly heat" or "heat rash" phenomenon

Miliaria

MC cause in kids. Child with idiopathic nephrotic syndrome improves after treatment with corticosteroids. The cause and pathogenesis is unclear and it is currently considered idiopathic.

Minimal change disease

Moderate proteinuria 1-3.5 g/day Classic presentation: - edema - HTN - hematuria - RBC Casts/dysmorphic RBCs - proteinuria 1-3.5 g/day - azotemia (elevated BUN/Cr)

Nephritic Syndrome

Severe proteinuria > 3.5 g/day Massive edema Fatty casts with "maltese cross" sign Hypoalbuminemia Hyperlipidemia Lipiduria Oval fat bodies

Nephrotic Syndrome

Fever is the earliest and only sign Hx of chemotherapy treatment DX: - CBC, CMP, blood culture, UA - CXR, CT/US, LP

Neutropenia

Treatment: Outpatient (low risk): Cipro + Augmentin; Moxifloxacin Monotherapy *pseudomonas: Cefepime, Imipenem, Augmentin Dual therapy: *unstable Monotherapy + Vanc or Flagyl (abd)

Neutropenia

Light red macules frequently found on the eyelids, nape of the neck, and forehead; occur secondary to areas of surface capillary dilation. These almost always resolve spontaneously by age 2 years, although some may persist into adolescence, at which time they may be treated with laser therapy.

Nevus Simplex (Stork Bite)

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 gait and appears unstable on his feet. He has an extensive erythematous, scaling, hyperkeratotic rash on his face, neck, arms and legs.

Niacin Deficiencies

Sources - Bran, tuna, salmon, chicken, beef, liver, peanuts, grains Function(s) - Energy, fat metabolism At-Risk Groups - Poverty, alcoholism Deficiency - Flushing

Niacin Deficiencies

Pneumonia when over 65

PCV15 followed by PPSV23 one year later OR PCV20

Patient's palm equates to 1%

Palmar Method for Burns

Placement of the examiner's finger in the infant's palm or sole should elicit the grasping reflex Disappears by 4 months of age.

Palmar and Plantar Grasp

Period of extreme anxiety that peaks within 10 minutes, typically declines within 30 minutes, and rarely lasts for longer than 1 hour. May have a definable trigger or be totally unexpected.

Panic Attacks

Symptoms: palpitations or tachycardia sweating trembling dyspnea/hyperventilation sensation of choking chest discomfort nausea depersonalization (feel estranged from self and/or the external world) derealization (people, events, and surroundings appear to be changed or unreal) fear of losing control fear of dying light-headedness numbness or tingling chills hot flashes

Panic Attacks

Treatment: First Line: SSRIs (sertraline, paroxetine) Short-term benzodiazepines to decrease anxiety Trazodone for treating insomnia. Prazosin may be used to alleviate nightmares. Crisis counseling should be initiated as a preventive measure when feasible. Support groups, family therapy, and cognitive or behavioral therapies are recommended. Single-session debriefing after the traumatic event has not been found to be effective in preventing this

Panic Attacks

Treatment: Benzodiazepines (alprazolam or lorazepam) for acute anxiety SSRIs while benzo's are tapered for maintenance - Paroxetine is beneficial, as are fluoxetine, venlafaxine, and sertraline Treatment should continue for 8 to 12 months, because relapse rates are high after medication is discontinued

Panic Disorder

Breast Tanner Staging 5

Recession of secondary mound, smooth contour, fully mature (~ age 14.5)

Shows increased uptake in Graves disease and toxic multinodular goiter Uptake is more diffuse and symmetric in Graves disease Should never be done in pregnant women or in those with laboratory-confirmed disease

Radioactive Iodine Uptake

Lispro, Aspart, Glulisine Duration: 4-5 hours Take 15-20 minutes before a meal

Rapid Acting Analog Insulin

Crescent formation on biopsy due to fibrin and plasma protein deposition Goodpasture's syndrome Vasculitis Microscopic polyangiitis Granulomatosis with polyangiitis (Wegener's)

Rapidly progressive glomerulonephritis

Run a soft, clean cloth over baby's gums twice a day - after the morning feeding and before bed - can keep food debris and bacteria from building up in the baby's mouth When a baby's first teeth appear - use a small, soft-bristled toothbrush to clean teeth twice a day Until children learn to spit — at about age 3 - use a smear of fluoride toothpaste no bigger than the size of a grain of rice - switch to a pea-sized dollop as children approach 2 to 3 years of age at or near his or her first birthday

Routine dental care

"3-day rash" Pink light-red spotted maculopapular rash First appears on the face, spreads caudally to the trunk and extremities Becomes generalized within 24 hours (lasts 3 days) Lymphadenopathy (posterior cervical, posterior auricular)

Rubella

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 1 day. She also reports that her daughter has a mild fever and redness in her eyes. She has not been vaccinated per parents' preferences. 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

AKA German Measles

Rubella

Etiology: Virus of its name Incubation Period: 14-21 days Prodrome: None Rash: Maculopapular, from head to toe Comments: Teratogenic

Rubella

Teratogenic in 1'st trimester - congenital syndrome - deafness, cataracts, TTP, mental retardation

Rubella

Head 9% Each arm 9% Chest 9% Abdomen 9% Each anterior leg 9% Each posterior leg 9% Upper back 9% Lower back 9% Genitals 1%

Rule of Nines for Burns

Canagliflozin

SGLT2 Inhibitor

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

Clinical features: Asymmetry in the shoulder and iliac height Asymmetric scapular prominence Flank crease with forward bending, showing right thoracic and left lumbar prominence Gait and neurologic examinations are normal. Curves of less than 20 degrees, diagnosed less than 2 years postmenarche, and Risser stage 2 to 4 are less likely to progress than are other curves.

Scoliosis

Imaging: Single, standing AP radiographs if scoliometer readings of greater than 5 degrees Vertebral levels are identified on radiography. The greatest anterior tilt is measured by the Cobb method (measurement is perpendicular to the end plate of the most tilted [end] vertebra). - Curves of greater than 15% are significant. - Accurate measurement is best performed by an orthopedic specialist.

Scoliosis

Secondary to underlying causes (i.e., upper or lower motor neuron disease, myopathies) Idiopathic adolescent = MC spinal deformity evaluated by a clinician. - highest risk = girls b/n onset of puberty growth spurt and cessation of spinal growth A thoracic curve to the left is rare; other spinal cord pathology needs to be ruled out before making a diagnosis

Scoliosis

Treatment: Curves of 10 to 15 degrees - 6- to 12-month follow-up with clinical evaluation and possibly x-rays. Curves - 15 to 20 degrees need serial AP radiographic - every 3 to 4 months for larger curves - every 6 to 8 months for smaller curves or for patients near the end of growth Curves of 20 degrees or greater - referral to an orthopedist for continuous monitoring and management (bracing, electrical stimulation, or surgery).

Scoliosis

presents with swollen gums, bruising, petechiae, hemarthrosis, anemia, poor wound healing, perifollicular and subperiosteal hemorrhages, and corkscrew hair

Scurvy

Predominance of fall or winter onset of depression Caused by the lessening daylight hours Typically remits in the spring. MC in colder climates and in females Treatment: - Light therapy - SSRIs - bupropion

Seasonal affective disorder

Superficial partial-thickness burns that extend to the papillary dermis - thin walled fluid filled blisters Deep superficial burns that extend into the reticular dermis - thicker walled, ruptured blisters

Second Degree Burns

Transient disturbances of cerebral function caused by abnormal paroxysmal neuronal discharges in the brain Diagnosed with EEG

Seizure Disorders

Treatment: Generalized convulsive and focal - Lamotrigine - Carbamazepine - Phenytoin - Valproic acid - Phenobarbital - Topiramate. Generalized nonconvulsive: - Ethosuximide - Valproic acid

Seizure Disorders

Occurs with damage/impairment of the inner ear (cochlea) or neural pathways. Presbycusis Meniere disease Acoustic trauma Acoustic neuroma

Sensorineural hearing loss

Use of MAOIs with SSRIs contraindicated Symptoms - rapid onset acute mental status change - restlessness - n/v - diarrhea - diaphoresis - tremor - seizure - muscle rigidity - coma/death Management: - stop offending agent - IV hydration - aggressive cooling - benzodiazepines to lock serotonin

Serotonin Syndrome

Studies that can detect the specific abnormal globulin of multiple myeloma

Serum and urine protein electrophoresis

Symptoms throughout day Nighttime symptoms nightly FEV1 <60% FEV1/FVC reduced >5% Extreme limitation with daily activities What asthma classification?

Severe Persistent

Retinal hemorrhages or hyphema should alert suspicion of what?

Shaken baby syndrome

Bases (Clorox, Drano)

Small amounts of water as dilutant No vomiting

Caustics (toilet bowel cleaners) antidote

Small amounts of water or milk No vomiting

Lactose is digested by lactase, which is produced where?

Small intestine

Nocturnal hypoglycemia followed by rebound hyperglycemia due to a surge in growth hormone Treatment: - decreased nighttime NPH dose or give bedtime snack

Somogyi effect

Pubic Hair Tanner Staging 2

Sparse straight hair

What is the most common site of bony metastases?

Spine

These two are the earliest reflexes. Stroking the face elicits turning of the head toward the stimulus When offered a nipple or the examiner's finger, the infant instinctively suckles.

Sucking and rooting

At highest risk after initiating tx Higher rates: - previous attempt - white males > 45 y.o. - detailed plan - self destructive pattern - poor support system - poor health - substance abuse - inability to accept help

Suicide

Topical burn ointment used

Sulfadiazine

Glyburide Glipzide Glimeperide

Sulfonylureas

Stimulates pancreatic beta cell insulin release (Insulin secretagogue) SE: Hypoglycemia

Sulfonylureas

Respiratory Syncytial Virus vaccine for children with lung issues or born premature/immunocompromised Once per month for five months beginning in November

Synagis prophylaxis

Uncomplicated cystitis treatment

TMP-SMX or Nitrofurantoin

Go away without treatment, but antihistamine medications are often helpful in improving symptoms If anaphylaxis give epinephrine

Urticaria (Hives)

Secondary Hyperthyroidism labs

TSH high T3/T4 high

Primary hypothyroidism labs

TSH high T3/T4 low

Primary Hyperthyroidism labs

TSH low T3/T4 high

Secondary hypothyroidism labs

TSH normal T3/T4 low

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

Classic signs and symptoms: Excessive drooling Chewing on objects Irritability or crankiness Sore or tender gums A slight increase in temperature — but no fever

Teething

Treatment: Chewing on a chilled [not frozen] ring or other devices - Rings and other chewing devices should be one piece - These devices should not be dipped in sugary substances - Necklaces, bracelets, or anklets that are made of beads should be avoided Avoid OTC or prescription topical analgesics (eg, lidocaine, benzocaine) for pain If especially fussy - Acetaminophen (Tylenol) - Ibuprofen (Advil, Motrin)

Teething

Common characteristics: Short stature Webbed neck Prominent ears Low posterior hairline Broad chest with widely spaced nipples Increased carrying angle Congenital lymphedema. Other characteristics may include: - hearing impairment - visual and spatial perceptive disabilities - primary amenorrhea - ovarian dysgenesis - absence of secondary sex characteristics - coarctation of the aorta - horseshoe kidney - aortic stenosis

Turner Syndrome

Diagnosis: Based primarily on physical exam and patient history Labs ⇒ low anti-Mullerian hormone Karyotype analysis is the diagnostic test of choice Fertility testing may identify 45XO, confirming the diagnosis Endoscopy may identify GI telangiectasias causing lower GI bleeding

Turner Syndrome

Manual detorsion

Twisting the testes outward and laterally

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

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

Causes: - infection (acute otitis media) - trauma (i.e., barotrauma, direct impact, or explosion). Most cases will resolve on their own; Surgical repair of the tympanic membrane as well as the ossicular chain (with persistent hearing loss) may be necessary. Water/moisture to the ear should be avoided to prevent a secondary infection that can impede closure.

Tympanic Membrane Perforation

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 has dry skin noted on physical exam.

Vitamin A Deficiency

Sources - Liver, fish oils, fortified milk, eggs Function(s) - Vision, epithelial cell maturity, resistance to infection, antioxidant At-Risk Groups - Elderly, alcoholics, liver disease Deficiency - Night blindness, dry skin Toxicity - Skin disorders, hair loss, teratogenicity

Vitamin A Deficiency

MC cause = pernicious anemia because of a lack of intrinsic factor Other causes - strict vegan diet - gastric surgery - blind loop syndrome - pancreatic insufficiency - metformin use - Crohn disease. Irreversible neurologic damage can be caused by uncorrected deficiency. Absorption occurs in the terminal ileum and storage is in the liver.

Vitamin B12 Deficiency

Treatment: Lifelong supplemental vitamin B12 given IM for pernicious anemia. Daily oral cobalamin may be effective, especially after an adequate parenteral loading. Strict vegans; patients with gastric bypass, gastrectomy, or resection of the ileum; and those with blind loop syndrome require vitamin B12 supplementation Neurologic signs and symptoms are reversible if treated within 6 months.

Vitamin B12 Deficiency

↑ Methylmalonic acid ↑ Homocysteine Hypersegmented neutrophils Poikilocytosis Stocking glove paresthesia Loss of position, fine touch, and vibratory sensation Balance problems and ataxia Dementia What macrocytic anemia?

Vitamin B12 Deficiency

Macrocytic Anemias

Vitamin B12 Deficiency Folate Deficiency

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 bleed after 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 disorder at 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

Responsible for scurvy The body cannot synthesize, must obtain from the diet Risk factors include: - food insecurity - feeding infants evaporated/boiled cow's milk

Vitamin C Deficiency

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

Sources - Fortified milk Function(s) - Calcium regulation, cell differentiation At-Risk Groups - Elderly, shut-ins with low sun exposure Deficiency - Rickets, osteomalacia Toxicity - Hypercalcemia, kidney stones, soft-tissue deposits

Vitamin D Deficiency

what is the main use for respiratory flouroquinolones?

upper and lower URIs