Pediatrics Flashcards
(341 cards)
1
Q
Timeline of newborn assessment in first 2yr of life?
A
Initial assessment within 24hr birth
Within 1 week post-d/c (if newborn exam at hospital)
2, 4, 6, 9, 12 mo
15, 18, 24 mo
2
Q
Should all infants receive Vitamin D?
A
All exclusively breast-fed infants should have supplemental Vitamin D, minimum 400 IU/d
3
Q
Apgar score
A
HR: 0 (absent), 1 (<100 bpm), 2 (>100 bpm)
Respiratory effort: 0 (absent), 1 (weak cry, hypoventilation), 2 (good effort, crying)
Muscle tone: 0 (flaccid), 1 (some flexion), 2 (well flexed, active)
Reflex irritability: 0 (no response), 1 (grimace), 2 (cry/ cough/ sneeze or withdrawal)
Color: 0 (blue/pale), 1 (acrocyanotic), 2 (completely pink)
4
Q
How long to exclusively breastfeed?
A
6 mo of life
5
Q
Will EtOH and recreational drugs enter breast milk?
A
Yes
6
Q
Contraindications to breastfeeding?
A
- HIV
- Active TB (until 2wk of appropriate tx complete)
- chemotherapy/nuclear medicine
- high-dose metronidazole (12-24hr after dose)
- illicit drug use
7
Q
Ddx delayed passage of meconium?
A
> 24hr after birth
- Hirschsprung disease
- Meconium plug/ileus
- CF
- Anal stenosis
- Anal atresia
8
Q
Investigations jaundice in 24h life
A
Inv - bilirubin (total, direct, indirect) - DAT (Coombs test) - ABO group (if mother blood group O) - minor group antigen screen - Rh status (and if RhoGAM was given) - assess for sepsis with consideration of FSWU \+/- risk factors (G6PD deficiency) - assess feeding and hydration - signs birth trauma (cephalohematoma, bruising)
9
Q
If newborn has central cyanosis what kind of saturation’s do you want to get?
A
Pre and post-ductal saturations
10
Q
What do you want to rule out in newborn with pallor?
A
- anemia
- asphyxia
- shock
- edema
- blood loss into head from birth trauma
11
Q
Define SGA and LGA babies
A
SGA = BW <10th percentile LGA = BW >90th percentile
12
Q
Weight loss red flags in newborn?
A
- loss >10% BW in first 7d life
- failure to regain BW by 10d of life
13
Q
Define microcephaly and macrocephaly
A
- microcephaly: >2 SD below mean (<3rd percentile) for gestational age
- macrocephaly: >2 SD above mean (>97th percentile) for gestational age
14
Q
Workup bulging fontanelle in newborn?
A
- assess for signs ICP, fever, signs of meningitis, neurologic deficits
- head US
- CBC, blood/urine cultures, glucose, electrolytes, urea, Cr
- consider transfer to tertiary centre
15
Q
Types of head trauma in newborn?
A
- caput succedaneum: diffuse edema (may cross midline and suture liens), may be ecchymotic
- cephalohematoma: limited to surface of one cranial bone, no overlying discolouration, firm tense mass with palpable rim, presents after birth with gradual increased size
- subgaleal hemorrhage: firm, diffuse, fluctuant mass that increases in size after birth (bleeding can be extensive into large potential space beneath epicranial aponeurosis)
-> monitor frequent vitals/assessments for perfusion, head circumference, hypotension, hyperbilirubinemia, blood loss (Act), or consumptive coagulopathy (DIC)
16
Q
What is abnormal red reflex? Management?
A
- white reflex (leukocoria), dark sports, absent reflex, asymmetric reflex
Urgent referral to ophthalmologist to r/o tumor (e.g. retinoblastoma), cataracts, other pathology of lens, vitreous or retina
17
Q
Is high arched palate normal in newborn?
A
- may be syndromic - refer
18
Q
What are normal neonatal murmurs?
A
- persistent pulmonary flow murmur
- transient systolic murmur re: closing PDA
19
Q
What are features consistent with pathologic murmur?
A
- diastolic/pansystolic murmurs
- harsh
- radiation
- no change with position
- abnormal S2
20
Q
Cardiac red flags in neonate?
A
- murmur
- cyanosis
- FTT
- tachypnea
- diaphoresis with feeding
21
Q
Workup murmur/ cardiac red flags in neonates?
A
- 4 limb BPs
- pre (right arm) and post-ductal O2 saturation
- ECG
- ECHO
- referral to paediatric cardiologist
22
Q
Workup increased RR without increased work of breathing (effortless tachypnea) in neonate?
A
- r/o CHF, acidosis, sepsis Inv - VBG - lactate - CXR - look for clinical signs congenital heart disease and sepsis
23
Q
Workup increased work of breathing and/or expiratory grunting in neonate?
A
- *immediate
- investigate signs of serious cardiopulmonary disease, sepsis
- VBG
- lactate
- CXR
24
Q
Workup palpable mass in neonate?
A
US to look for etiology
25
Normal palpable liver in neonate?
- up to 2cm below costal margin
| +/- spleen tip
26
Workup abdominal distention, and/or scaphoid abdomen and respiratory distress in neonate?
- AXR to r/o obstruction (meconium ileus if shortly after birth), perforation
- CXR to r/o congenital diaphragmatic hernia
27
What umbilical sign increases risk of occult renal abnormality?
2 vessel cord (1 artery + 1 vein)
| - monitor and consider US
28
Management of ambiguous genitalia?
Urgent evaluation and referral -> can be due to life-threatening etiology
29
Management clitoromegaly in female neonates?
- r/o congenital adrenal hyperplasia (can be life threatening)
30
Management/workup imperforate anus?
- X-ray as initial investigation
| - surgical management
31
Workup hip click on neonatal exam?
Ortolani and Barlow -> +
= US to look for DDH
- note hip click can be normal, originating from fascia and/or tendons
32
Workup congenital scoliosis?
Investigations for associated pathologies
- US for renal pathology
- cardiac exam +/- ECHO
- MRI for possible intraspinal pathology
33
Management hair tuft/dimple over lumbosacral spine?
- investigate underlying pathology (occult spina bifida, tumor, sinus tract)
- US
34
Name normal neonatal rashes
- erythema toxicum
- pustular melanosis
- dermal melanocytosis (Mongolian spots)
- harlequin color change
35
Management abnormal irrepressible movements, seizures in neonate?
- EEG
- paediatric neurologist assessment
+/- genetics/ metabolic
- consider MRI brain
36
Workup hyper/hypotonia in neonate?
- paediatric neurology
| - genetics/metabolics consults
37
Ddx asymmetric Moro reflex?
- clavicle fracture
- brachial plexus injury (birth trauma)
- hamiparesis
38
Management absent Moro in term neonate?
| Management obligatory ANTR (neonate becomes stuck in position)?
Suggests significant CNS dysfunction - full neurologic evaluation
39
What are the primitive neonatal reflexes?
- grasp
- suck
- Moro
- ANTR
40
Normal vitals in newborn (term)?
Wt 3-4kg
HR 90-170 bpm
RR 40-60 /min
sBP 70-90 mmHg
41
Define fever in neonate and management
Rectal 38.0
Axillary 37.3
FULL septic workup (CBC, blood C+S, urinalysis, urine C+S, lumbar puncture +/- CXR)
42
When do you do routine newborn screening?
- within first 7d life (ideally first 2-3d)
- varies by province -> inborn errors of metabolism, hemoglobinopathies, CF
+ additional screening re: risk factors
+ routine hearing screening
+ assessment of jaundice (+/- serum bilirubin) and feeding within first 24h of life
43
When does umbilical cord detach?
- 1-3wk after birth -> keep clean and dry, wash with water only
44
Safe sleep re: SIDs prevention
- sleep on back in empty crib first first year of life
Back to sleep, front to play
- room sharing reduces risk of SIDS
- bed sharing and tobacco exposure increase risk of SIDS
45
Typical weight gain in infants
180g/wk until 4-5mo (1oz per day except Sundays)
2x BW by 4-5mo
3x BW by 1yr
4x BW by 2yr
46
What is omphalitis?
Umbilical cord infection
- fever
- purulent d/c
- redness and swelling
- foul odor
- bleeding (more than few drops)
47
What is most important risk factor for infant mortality + significant determinant of infant and childhood morbidity?
Low birth weight
48
Complications of SGA?
- difficult cardiopulmonary transition
- complications of prematurity
- impaired thermoregulation
- hypoglycemia
- polycythemia (hypoxia = increased EPO)
- impaired immune function
- perinatal mortality
49
List complications of prematurity
- RDS (resp distress syndrome)
- ROP (retinopathy of prematurity)
- intraventrivular hemorrhage (IVH)
50
Complications of LGA
- increased risk of cesarean delivery, severe postpartum hemorrhage, vaginal lacerations
- birth injury (brachial plexus, shoulder dystocia, clavicular #)
- respiratory distress (RDS if mom DM, TTM if born c/s, meconium aspiration)
- perinatal asphyxia
- hypoglycaemia
- polycythemia (hyperinsulemia -> increased demands -> hypoxia -> increased EPO)
- increased perinatal mortality
- minor congenital anomalies
- propensity adult obesity
51
Define IUGR
- fetus hasn't reached growth potential because genetic or environmental factors, resulting in SGA infant
52
What is Barker hypothesis?
- adverse stimuli or events occurring in utero and during infancy can permanently change body's structure, physiology and metabolism, which can influence occurrence of many diseases that will develop in adulthood
53
Rule to calculating fundal height after 12wk GA?
- fundal height (cm) = week gestation +/- 2
54
Classification of IUGR?
- symmetric: symmetric reduction in anthropometric measurements, usually due to early gestational insult
- asymmetric: reduced body weight with relatively normal length and head growth, usually due to gestational insult affecting growth in late 2nd/ 3rd trimesters
55
How do you screen for and diagnose SGA/IUGR?
prenatal US estimation of fetal weight
| - also assesses biometrics (e.g. biparietal diameter, femur length) and amniotic fluid volume
56
When is fetal karyotyping recommended for IUGR?
- early (<32wk)
- severe (<3rd percentile)
- accompanied by polyhydramnios or structural anomalies
57
What maternal assessments are indicated if IUGR recurrent, early, severe, or postive FHx thrombophilia?
- maternal thrombophilic disorders assessment
58
Abnormal weight in newborn investigations
- CBC
- blood gases (hypoxia -> acidosis)
- glucose (hypoglycaemia)
- chemistry (hyperbilirubinemia, hypoCa)
- blood/urine/CSF cultures pro
- drug screen
+/- genetics, other testing
59
Ballard score (GA assessment)
1. extent that sole of foot covered in creases
2. presence and size of breast buds
3. features of scalp hair
4. formation of ear cartilage (pinna recoil)
5. appearance of genitalia
6. neurologic assessment of posture, active and passive tone, and reflexes
60
Use of Doppler of umbilical artery in utero?
- identify small fetus at risk for adverse perinatal outcomes (preterm birth, NICU admission, asphyxia, etc)
- > NOT useful for screening and dx of IUGR
61
Which is often pathologic - conjugated or unconjugated hyperbilirubinemia?
- conjugated hyperbilirubinemia (>20% total bilirubin conjugated) is always pathologic
- -> must investigate
62
How is bilirubin produced?
- catabolism of hemoglobin
hemoglobin -> unconjugated bilirubin (not water soluble)
--> to liver --> UDP-GT conjugates bilirubin (water soluble)
- conjugated bilirubin broken into urobilinogen and stercobilinogen -> excreted in stool and (lesser degree) urine
63
Define kernicterus + sx
- neurologic outcome of bilirubin deposition in basal ganglia and brainstem nuclei
- result of elevated unconjugated hyperbilirubinemia
early sx: lethargy, poor suck, hypotonia, high-pitched cry, seizures
late sx: irritability, hypertonia, opisthotonos, fever
64
Risk factors severe hyperbilirubinemia
- jaundice within first 24h life
- blood group incompatibility (DAT +)
- late preterm infants (35-36 + 6wk GA)
- cephalohematoma
- sibling requiring phototherapy
- exclusively breast-fed
- east Asian race
- G6PD deficiency
65
Risk factors neonatal sepsis
- rupture membranes >18h before delivery
- maternal fever (>38) during labor
- chorioamnionitis
- maternal GBS colonization (i.e. GBS UTI)
- prior delivery of infant with GBS disease
66
Ddx unconjugated hyperbilirubinemia
Increased production
- extravascular blood (cephalohematoma)
- polycythemia
- red cell instability (G6PD, spherocytosis, etc.)
- Coombs positive (isoimmunization - Rh, ABO, minor antigens)
Decreased conjugation (UDP-GT deficiency)
- premature
- Gilbert syndrome
- Crigler-Najjar syndrome
- Congenital hypothyroidism
Increased reuptake (enterohepatic circulation)
- breast-feeding jaundice (secondary to dehydration)
- bowel obstruction (meconium ileus, etc)
67
Ddx conjugated hyperbilirubinemia
```
Sepsis
- Intrauterine infection (TORCH)
= toxoplasmosis
= other: syphilis, EBV
= rubella
= cytomegalovirus
= herpes, HIV
```
Hepatic
- biliary atresia
- Alagille syndrome
- disorders of bile acid metabolism
- neonatal hepatitis
- choledochal cyst
- underlying metabolic condition (Galactosemia, tyrosinemia)
- infiltrative (Wilsons, alpha 1 antitrypsin deficiency)
- TPN-related cholestasis
- CF
68
What is ABO isoimmunization?
- ABO incompatibility (mother blood type O, baby blood type A or B) is important cause of hemolytic disease of newborn that must be ruled out
- newborn with rapidly increasing bilirubin levels approaching levels for exchange transfusion, IVIG should be considered
69
Red flags for jaundice?
- <24h or >2wk age
- rate of rise of bilirubin >85 micro mol/24h
- toxic appearance
- risk factors for neonatal sepsis
70
Management of bilirubin level indicating treatment on nomogram?
- phototherapy +/- IVIG, IV hydration
- monitor serial serum bilirubin q6-8hr
nomogram re: risk factors and GA -> placed on low, intermediate or high risk zone
71
Routine jaundice investigations
- CBC
- blood smear
- total and direct bilirubin (absolute values and rate of rise)
- ABO blood type
- Coombs test
- electrolytes
+ specialized tests
- G6PD
- sickle cell screen
- hemoglobinopathy screen
- reticulocyte count
- sepsis workup
- metabolic evaluation (galactosemia screen, TSH, free T4)
- abdo US
- hepatobiliary imilodiacetic acid (HIDA) scan
72
Phototherapy treatment for jaundice
- photoisomerization of unconjugated bilirubin to water soluble isomers
- safe for mild to moderate hyperbilirubinemia
CI conjugated hyperbilirubinemia (bronze baby)
- potential for burns, retinal damage
- separation of infant and parents can be disadvantage
73
Pharmacologic tx jaundice
- IVIG - for isoimmune hemolytic disease
- heme-oxygenate inhibitors - for metalloporphyrins
- may reduce need for exchange transfusion
- unclear efficacy, long term effects
- may have sedative effects
74
Exchange blood transfusion for jaundice
- reserved for dangerously high levels or pt with sx kernicterus
- removes and replaces partially hemolyzed and antibody-coated erythrocytes
- most rapid method of tx
disadvantages
- NEC
- metabolic acidosis
- thrombocytopenia
- coagulopathy
- arrhythmias
- infection
- death
75
3 types of vaccines
- live attenuated: whole/weakened bacteria or virus; usually produce immunity with 1 dose
- whole inactivated: contain whole or part-killed bacteria or virus; does not cause disease it is designed to prevent; usually require >1 dose
- subunit: organism parts, protein/toxoid, polysaccharide +/- conjugate
76
What is active immunization?
- complex biologic products designed to induce protective immune response
77
What is passive immunization?
- prevent immunization: prevent infection and reduce severity of illness; used when vaccines for active immunization not available or contraindicated, unimmunized people exposed to agent, or in immunocompromised individuals
78
Do vaccinations work on individuals or population levels?
Both
79
Additives in vaccines?
- adjuvant (aluminum salt) to enhance immune response
- preservatives (thimerosal) to prevent serious secondary infections
- others (egg, animal protein, glycerol, formaldehyde) support stability and growth of antigens
80
Side effects of vaccines?
- common: fever, tenderness/swelling at injection site, tiredness, poor appetite, emesis
- MMR/VZV: 'pseudo-infection' (measles-like rash, parotitis, lymphadenopathy, arthralgia/ arthritis, mild varicella-like papules/vesicles), 1/40000 thrombocytopenia, 1/25000 febrile seizure
- DTaP: 1/14000 seizure, 1/1000 prolonged crying (>3h)
- occasionally more serious reactions (anaphylaxis, allergy)
81
NACI vaccination schedule
2 mo
- DTap-IPV-HiB
- rotavirus
- Men-C
- Pneum-C-13
4mo
- DTap-IPV-HiB
- rotavirus
- Men-C
- Pneum-C-13
6mo
- DTaP-IPV-HiB
- rotavirus
- Men-C
- Pneum-C-13
6-59 mo
- influenza (seasonal)
12mo
- MMR
- Varicella
- Men-C
- Pneum-C-13
18mo
- DTaP-IPV-HiB
- MMR
- varicella
4-6yr
- DTaP- IPV
- MMR
- varicella
Preteen
- Men-C-A, C, Y, W-135
- hepatitis B
- HPV
14-16yr
- Tdap or Tdap-IPV
82
Immunizations with asplenia/hyposplenic (congenital, surgical, functional)
- no CI to vaccines
- should receive influenza annually
- coverage of encapsulated organisms (Hib, N. meningitidis, S. pneumonia)
83
BCG vaccine?
- infants of parents with infectious TB at delivery
| - high risk populations (First Nations)
84
Indication for RSV immune globulin?
- children <24mo with prematurity (born <32wk GA), chronic lung disease, heart disease, or living in rural or remote location
85
Do you base timing of immunizations based on chronological or gestational age for premature infants?
- chronological age
86
Contraindications to vaccinations?
Previous anaphylactic reaction to vaccine or component
- components: gelatin (MMR), egg (influenza), yeast (hep B), streptomycin (DTaP)
Live vaccines: severe asthma/wheezing, pregnancy, severe immunodeficiency or active immunosuppression therapy, TB (MMR, MMRV, univalent varicella, herpes zoster, BCG)
Rotavirus: congenital malformation of GI tract or intussusception
Influenza: not to pt who had ocluo-respiratory syndrome after prior influenza vaccine
Relative CI:
- Guillain-Barre syndrome within 6wk vaccination
- moderate/severe illness
- rotavirus - moderate-severe gastroenteritis
87
How long do you delay live vaccination in patient who received antibody-containing blood products?
3-6mo (can interfere with endogenous antibody response)
88
Normal crying pattern baby?
- average 3h/d by 6wk of age
| - peak time between 3-11pm
89
How is infantile colic dx?
dx of exclusion
| - benign, self-limited condition beginning in first weeks of life and peaking during 2nd and 3rd month of life
90
Rome criteria for infantile colic
occurs in infants <4mo of age with:
1. paroxysmal without obvious cause
2. no effect on infants growth and development (no FTT)
3. lasts >3hr/d, >3d/wk (for >1wk)
91
Infant crying emergencies to rule out?
- hair tourniquet: remove tourniquet immediately and ensure blood flow returns
- testicular torsion: US doppler, urology referral
- glaucoma: refer ophthalmologist
- malrotation/volvulus: abdo plain films, gen surg
- intussusception: abdo US, air enema, surgery
- incarcerated/strangulated hernia: dx based on exam, inability to reduce hernia, consider US, gen surg
- septic arthritis: consider joint aspiration if clinical exam suspicious, abx
- abusive head trauma: head imaging, skeletal survey, involve child services and team for suspected cases of abuse
92
Management of colic
- educate parents, support
evidence conflicting
- hypoallergenic diet in mother if breast fed
- hypoallergenic formula if formula fed (e.g. hydrolyzed casein/ whey protein and amino acid based)
- probiotics/ probiotics
- alternative therapies
93
Full septic workup in neonate (<28d) with fever?
Yes
94
Measurement of temperature in peds
definitive
- <5yr = rectal
- >5yr = oral
rectal temp >38 fever
95
Normal temperature ranges
- rectal 36.6 - 38
- tympanic 35.8 - 38
- oral 35.5 - 37.5
- axillary 34.7 - 37.3
96
What dx is considered in subacute or chronic fevers (>2wk duration)?
inflammatory or malignant aetiologies
vs. acute fever (<2wk) often infectious
inflammatory
- consider autoimmune: SLE, JIA (salmon-pink rash)
97
What is a pyrogen?
- substance that produces fever
- portion of viruses or bacteria (lipopolysaccharide) or components of innate and active immune system (complement, antigen-antibody complexes)
98
What is Reye syndrome?
- encephalopathy and fatty degeneration of liver (significant morbidity and mortality)
- ASA in kids with varicella or influenza (NO aspirin to kids with febrile illness)
99
Where is the thermoregulatory centre? What can change the target range?
- hypothalamus -> maintains body temp in certain range
| - cytokines and pyrogens can alter target range
100
What is caused by increased cellular metabolism, i.e. involuntary skeletal muscle shivering?
increased heat production
101
What mediates the increase in set point of the thermoregulatory centre (targeting by antipyretics - NSAIDs, acetaminophen)?
PGE2
102
Mechanism of antipyretics?
PGE2 synthesis depends on COX
- antipyretics = COX inhibitors
- -> NSAIDs = COX inhibitors
- -> Acetaminophen oxidized in CNS to form inhibiting COX (poor peripheral tissue COX inhibitor)
- -> Glucocorticoids reduced PGE2 synthesis by inhibiting activity of phospholipase A2 (prevent arachidonic acid release) and block transcription of mRNA pyrogenic cytokines
103
Clinical signs meningitis?
- nuchal rigidity
- Kernig sign - upper leg flexed at 90 and extension of leg painful
- Brudzinki's sign - forced flexion of head results in involuntary flexion of hips
104
Kawasaki disease criteria
Fever at least 5d, and presence of at least 4/5:
- bilateral, non purulent conjunctivitis
- mouth/oropharyngeal changes - strawberry tongue, dry/ cracked erythematous lips
- polymorphous rash
- extremity changes- edema of hands and feet, in later stages can see desquamation (peeling) or periungual skin
- unilateral cervical adenopathy >1.5cm
105
What does full sceptic workup include?
```
CSF culture (bacterial, viral, fungal meningitis)
- often LP in fever <90d
Blood culture (bacteremia)
Urine culture (UTI + pyelonephritis)
CXR (pneumonia + empyema)
```
consider nasopharyngeal swabs for viruses, throat swab, and stool for virology/ bacteriology/ parasitology
106
Rochester criteria (re: septic workup)
For infants at low risk of serious bacterial illness
1. previously healthy term infant without perinatal complications and no previous antibiotic treatment
2. normal physical exam findings
3. WBC 5000-15000 cells/mm3
4. band count <1500 cells/mm3
5. urinalysis: <10WBC/HPF in centrifuged catheterized specimen
- partial septic workup considered in febrile infants 1-3mo of age at low risk of having serious bacterial illness
107
Signs of sepsis on exam
early
- peripheral vasodilation (tachycardia, bounding pulses, warm extremities, adequate cap refill)
late
- poor distal perfusion (cool extremities, delayed cap refill, altered mental status, reduced u/o)
septic shock (inadequate organ perfusion/ function)
- altered level of consciousness
- hypoxemia
- oliguria (<0.5 mL/kg/h)
108
Jones criteria
```
For acute rheumatic fever
Dx: 2 major criteria OR 1 major + 2 minor + evidence of recent GAS infection (positive culture or rising tigers)
Major (SPACE)
- subcutaneous nodules
- polyarthritis
- arthritis
- carditis
- erythema marginatum
```
Minor (LEAF)
- long PR interval
- elevated acute phase reactants
- arthralgia
- fever
109
Dose paediatric acetaminophen
10-15mg/kg q4h (max 75mg/kg/d, or 4g)
110
Does paediatric ibuprofen
10mg/kd q6h (max 40 mg/kd/d)
111
GAS pharyngitis tx
- Penicillin V or Amoxicillin
- penicillin allergic = cephalosporins or macrocodes
- > tx to prevent suppurative and nonsupprative complications
112
Common infectious organisms 0-28d and empiric tx
- common: group B streptococcus, E. coli
- other: S. aureus, Listeria monocytogens, Enterococcus, HSV, gram-negative orgamisms
empiric tx:
- ampicillin + cefotaxime OR
- ampicillin + amino glycoside
consider acyclovir
113
Common infectious organisms infant 29-90d and empiric tx
- common: S. pneumonia, H. influenza, N. meningitidis
- other: group B strep, E. coli, S. aureus, Enterococcus, Listeria monocytogenes, Pseudomonas sp., other gram negative orgamisms
empiric tx
- ampicillin + cefotaxime
consider vancomycin for suspected meningitis
114
Common infectious organisms if >3mo and empiric tx
- S. pneumonia, H. influenza, N. meningitidis, S. aureus
empiric tx
- ceftriaxone +/- vancomycin
115
Meningitis: common pathogens and tx
N. meningitides, S. pneumonia, HiB (rare now)
third-generation cephalosporin (crosses BBB) + vancomycin
116
URTI: common pathogens and tx
pharyngitis: GABHS
acute otitis media: S. pneumonia, NTHI, M. catarrhalis
penicillin, amoxicillin
117
Pneumonia: common pathogens and tx
S. pneumonia, GABHS, atypicals
ampicillin/amoxicillin
OR cefuroxime, macrolides
118
UTI common pathogens and tx
E. coli (others: Klebsiella, Enterococcus, Proteus, Serratia)
TMP-SMX, cephalexin or cefixime
119
Septic arthritis common pathogens and tx
S. aureus, Strep
Cloxacillin
120
Endocarditis common pathogens and tx
S. viridians (native valve)
IV penicillin G or ceftriaxone + gentamicin
121
Pediatric bolus amount in resuscitation and next step
20mL/kg 0.9% NS (push as fast as possible) x3
| - after 3 boluses consider vasopressors (dopamine, norepinephrine, epinephrine)
122
Abx contraindicated in peds?
- fluoroquinolones: impair bone/ cartilage growth
| - tetracyclines: stain teeth, damage growing cartilage
123
Antiviral medications for influenza?
- if dx confirmed and pt at increased risk of severe or complicated influenza due to underlying chronic illness or kid has severe illness requiring hospitalization
Neuraminidase inhibitors - reduce release of influenza A and B from infected cells (Tamiflu)
Tricyclic amines - inhibit replication of influenza A (amantadine or rimantadine)
124
Centor/McIsaac score (GAS pharyngitis) and diagnosis/tx
- fever >38 (+1)
- no cough (+1)
- tonsillar exudates/erythema (+1)
- tender anterior cervical lymphadenopathy (+1)
- age 3-14 (+1)
0-1 = no culture
2-3 = culture, only treat if +
>=4 = treat with abx
- rapid strep antigen test (70-90% sensitive)
- throat culture (gold standard)
tx- 10d penicillin or amoxicillin (erythromycin if penicillin allergy)
125
Ddx pharyngitis
- bacterial: GAS
- viral: EBV, adenovirus, influenza, parainfluenza, coxsackie A
- fungal: C. albicans
- allergic
- other, e.g. Kawasaki disease, foreign body
126
Croup: sx, dx, tx
- URTI, hoarse voice + barking cough, fever, stridor
- lateral neck X-ray: subglottic narrowing
- frontal neck film: steeple sign in subglottic region
supportive tx, neublized racemic epinephrine for stridor, single-dose systemic steroid
127
Bacterial tracheitis sx, dx, tx
- preceding URTI, high fever, stridor, retractions, dysphagia, muffled/suppressed cough, toxic
- clinical suspicion
- CXR: subglottic narrowing similar to croup
- positive tracheal aspirate
emergent intubation
empiric tx, IV abx (cefuroxime)
128
Epiglottitis sx, dx, tx
- rapid sx evolution: fever, sore throat, irritable, lethargy, drooling; dysphagia, severe stridor/ airway obstruction, toxic
- clinical suspicion
- direct visualization in OR
- keep in comfortable position
- intubate
- IV abx: third/fourth generation cephalosporin
- steroids not indicated
129
RPA sx, dx, tx
- prodromal nasopharyngitis + abrupt onset high fever, dysphagia, respiratory distress; drooling, meningismus
- lateral neck X-ray: widening of retropharyngeal space
IV abx: clindamycin, first or second generation cephalosporin and metronidazole
- emergent surgical drainage
130
Peritonsillar abscess
- sore throat, ipsilateral ear pain, trismus, hot potato voice, fever
- mass effect: deviated uvula; cervical adenopathy, fluctuance, WBC elevated, throat culture +
surgical drainage or tonsillar aspiration
IV abx
131
Tests for EBV
- heterophil antibody test = mono spot test for EBV
- EBV tigers
+ lymphocytosis on CBC
132
Complications GAS pharyngitis
- rheumatic fever
- post-streptococcal glomerulonephritis
- retropharyngeal/ peritonsillar abscess
- scarlet fever
--> tx prevents rheumatic fever
133
Management EBV pharyngitis
- supportive
+/- steroids if airway obstruction
- no contact sports x4wk (protect spleen)
134
Normal RR by age (0->12)
```
0-3 mo: 35-55
3-6 mo: 30-45
6-12 mo: 25-40
1-3 yr: 20-30
3-6 yr: 20-25
6-12 yr: 14-22
>12 yr: 12-16
```
135
Signs of increased work of breathing?
- head bob
- nasal flare
- tracheal tug
- substernal and intercostal retractions
- subcostal recessions
- paradoxical thoraco-abdo movement
136
Define respiratory failure and types
- inadequate gas exchange (oxygenation or ventilation)
```
type I (hypoxemic): decreased oxygen exchange (PaO2 <60mmHg)
- often due to ventilation-perfusion (V/Q) mismatch; can be caused by anemia, poor blood flow to lungs (sepsis, cardiac failure), or toxins affecting utilization of O2 at tissue level (cyanide)
```
```
type II (hypercapnic): decreased removal of carbon dioxide (PaCO2 >50mmHg or pH <7.35)
- reduced RR (bradypnea) or reduced tidal volume (shallow breaths)
```
137
Paediatric respiratory assessment measure (PRAM)
| - components
```
Quantify level of respiratory distress
scored 0-3 per category (0 = no signs; 3 = severe)
- suprasternal indrawing
- scalene retractions
- wheezing
- air entry
- O2 saturation
```
```
0-3 = low risk
4-7 = moderate risk
>8 = high risk
```
138
What can a normal or increasing CO2 level in context of tachypnea and respiratory distress indicate?
- fatigue --> impending respiratory failure
139
Retropharyngeal abscess (RPA)
- sx
- X-ray findings
- serious condition may present with fever, neck pain (or torticollis) and refusal to eat
- X-ray neck: increased width of prevertebreal soft tissue (> half width of corresponding vertebral body then abnormal and r/o RPA)
140
Management of bronchiolitis
- supportive, can suction nares
- O2 for sat >90%
- trial bronchodilators option
- high risk kids should receive RSV prophylaxis (palivizumab)
141
Management acute asthma exacerbation
Mild (PRAM 0-3)
- supplemental O2 to keep O2 >94%
- short-acting bronchodilator (Salbutamol) q20 min x 1 -3 doses then q1h prn
- consider systemic steroids
Moderate (PRAM 4-7)
- O2 to keep O2 >94%
- continuous O2 monitoring
- Salbutamol +/- Ipratropium bromide q20min 3 doses then q30min prn
- system sterioids
Severe (PRAM >8)
- supplemental O2 for O2 >94%
- continuous O2 monitoring
- Salbutamol and Ipratropium bromide q2min x3 then salbutamol q30min prn
- systemic steroids - IV if no PO intake
- consider IV fluids containing K
- if not improving, treat with magnesium sulfate
- if resp distress persists, consider continuous salbutamol infusion and admission to ICU
- be prepared for rapid sequence intubation
steroids: prednisone or dexamethasone for 3-5d
142
Ddx child with stridor
croup
epiglottitis
foreign body aspiration
143
Approach to croup
- inflammation of larynx and trachea, often secondary to viral infection (parainfluenza accounts for 65%)
- kids 1-6yr old
- hx: preceding vital URTI (cough, coryza, fever)
- sx: barking cough, inspiratory stridor
- ix: steeple sign on PA radiograph of upper airway
- tx: systemic steroids +/- nebulizer epinephrine
144
Approach to epiglottitis
- infection and inflammation of epiglottis, with high risk upper airway obstruction
- most commonly due to HiB (important to ask about vaccination status of kid)
- sx: toxic appearance, drooling, muffled voice, tripod positioning
- ix: thumb print sign on lateral neck radiograph
- tx: intubation, abx
145
Approach to foreign body aspiration
- must be considered in stridorous child regardless of hx
- peanuts are most common aspirated foreign body in children
- ix: AP radiographs can determine if there is a radiopaque object present; lateral decubitus radiographs may demonstrate air trapping on the side with foreign body present
- tx: broncoscopy
146
How to deliver salbutamol?
- MDI via Aerochamber
| - can be delivered by nebulizer
147
Salbutamol effect on K
- shifts K into cells lowering serum K
| - monitor K closely if multiple salbutamol doses
148
What layer of skin are melanocytes and Langerhans cells found in?
epidermis (outermost layer)
149
What layer of skin contains collagen, elastic tissue and reticular fibres, hair follicles, sebaceous (oil) and eccrine (sweat) glands, blood vessels and nerves?
dermis
150
What layer of skin is subcutaneous fat and connective tissue found in?
subcutis/hypodermis
151
Is pruritus thought to be due to a higher number of sensory fibres or adrenergic autonomic nerve fibres?
higher around of sensory fibers
152
What is erythema toxicum?
- most common neonatal rash
- noninfectious, benign papular rash that can evolve into vesicles; clustered lesions, often developing within days of brith but up to few weeks of age
- self-limited, resolution within 1wk
- recurrences may occur
153
What is miliaria (different than milia)?
- papule and pustules on erythematous base usually around nose (prickly heat rash)
- secondary to eccrine sweat duct obstruction
- onset after first wk life, predilection for areas with high heat production
- self-limited though supportive tx; minimize excessive wrapping can facilitate improvement
154
What is congenital dermal melanocytosis (Mongolian blue spot)?
- benign blue-purple large, usually patchy skin macules
- common in Aboriginal, Asian, African American, and other dark-toned infants
- sites: often buttocks, legs, spine, but can occur anywhere
- must ensure not non accidental injury
- spontaneous resolution within 1yr, some may persist
155
What is molluscum contagiosum: Poxvirus?
- small pink-tan (flesh-coloured), dome shaped papoules with dimpled or umbilicated centre; can express curd-like material
- usually asx, but can be associated with exzematous dermatitis and pruritis
- rx: none - course self-limited in healthy kids, spontaneous regression within 2yr
- -> options include destructive methods (curettage, cryotherapy, peeling agents, topical retinoids, cantharidin)
- if persistent/widespread, screen for congenital or acquired immunodeficiency
- complications: bacterial superinfection requiring abx
156
What is a hemangioma?
- newborn: pale macule with thin telangiectasia (thread-like)
- older kids: vibrant, red, elevated, non compressible plaque sometimes with blue tinge indicating deeper components
- only 10% present at birth; grow larger until 10-12mo age then natural regression over subsequent 3-5yr
complications: rare but can ulcerate with seondary infection, hemorrhage, and scarring
dx- clinical; US to differentiate vascular malformation or neoplastic process and visualize extent of deeper infiltration
rx- none
- b-blocker (nadolol, propranolol) are first-line if face or requires tx
- systemic steroids, laser ablation, interferon tx, embolization, or surgical excision depending on number, location, depth of lesions
157
What is epidermolysis bullosa?
- group of heterogenous mechanobullous diseases characterized by development of blisters after trauma to skin
types:
- EB simplex (non scarring)
- dystrophic EB (severe scarring, atrophy, multi system involvement)
- junctional EB (often fatal or heals with atrophy, can present with airway compromise due to granulation tissue)
rx- education, symptomatic tx, monitor thermoregulation, fluid balance and airway potency, assess for secondary infections with extensive blistering; support groups; scarring can lead to internal and external deformities/strictures that have functional and cosmetic implications
158
What is viral exanthem?
- morbilliform red eruption, usually nonpruritic
- extremely common; multitude of viral strains can cause
- may be febrile, well-appearing child
- usual sites: trunk +/- extremities
- associated with measles, rubella, roseola, enteroviruses, mononucleosis
- rx: self limiting; monitor sx
159
What is varicella zoster virus infection?
Chicken pox
- prodrome of mild fever and other systemic sx
- generalized, polymorphous, pruritic, vesicular rash (dew drop on rose petal) of abrupt onset at varying stages of healing
- severe infection less common with vaccine, often present atypically
- latency in dorsal root ganglia during primary infection -> reactivation -> shingles
- primary infection usually results in life-long immunity but recurrence can occur
transmission: airborne from respiratory secretions, direct contact of lesions, transplacental
- incubation period: 10-21d; contagious 1-2d prior to onset of rash and until crusting of all lesions complete
dx- clinical; can send vesicular scraping for direct fluorescent antigen/EM/PCR
rx- supportive
- if immunocompromised can give acyclovir, VZIG +/- vaccination
160
Which infectious rash (common in peds before vaccination) can result in these complications: bacterial superinfection, thrombocytopenia, arthritis, hepatitis, cerebellar ataxia, encephalitis, meningitis, glomerulonephritis, pneumonia
Varicella zoster
161
Perinatal/neonatal disease of varicella zoster?
- high risk if onset of maternal skin lesions 5d before delivery or 2d after delivery
- mortality rate 30% due to encephalitis
- VZIG in immediate postpartum period to prevent
- rx with IV acyclovir if baby develops varicella
162
Coxsackie virus A16 is what?
Hand-foot-and-mouth disease
- red coloured macule, vesicular lesions on buccal mucosa, palate, tongue, hands (palms), and feet (soles)
- viral prodrome
- exquisitely tender lesions
transmission: direct contact
rx- supportive, PO fluid, lidocaine mouthwash
163
Morbillivirus?
Measles
- fever, cough, coryza, conjunctivitis (3Cs)
- diffuse maculopapular rash
- transient enanthemas (Koplik spots - pathognomonic)
- rash starting on face and spreading caudally
- risk of death from resp and neuro complications
transmission: resp droplet
incubation period 8-12d
tx- supportive + vitamin A supplementation; consider post-exposure prophylaxis (vaccine, immunoglobulin)
- pubic health notification
164
What are Koplik spots pathognomonic for?
Measles
165
Parovirus B19 (erythema infectiousum)
Fifth disease
- prodrome fever, malaise, myalgia, approx 7d before rash
- red 'slapped cheek' rash with circumoral pallor
- maculopapular, lace-like, pruritic rash on trunk, moving peripherally
- other sx: polyarthropathies, anemia (immunocompromised), transient aplastic crisis (hemolytic anemia), hydrops fetalis (first trimester of pregnancy)
transmission: resp droplet
incubation period 4-14d
rx - supportive
166
HSV 1&2
- primary infection usually asx
- gingivostomatitis: fever, irritability, tender lymphadenopathy, ulcerative enanthem in anterior oropharynx
- genital herpes in adolescents
- recurrence - grouped vesicles personally or genital, conjunctivitis, herpetic whitlow
- transmission: direct contact with secretions from lesions, sexual intercourse
- incubation period 2d - 2wk
rx- supportive, ensure PO intake, lidocaine mouthwash
167
Neonatal HSV
- 1 in 3200 to 10000
classification:
- Localized skin, eye, mouth (SEM): coalescing/ clustering vesicular lesions; tearing, ocular pain, conjunctival deem +/- localized ulcerative lesions of mouth, palate, tongue -> eval all for CNS and disseminated disease
- CNS +/- SEC: seizures (focal/generalized), lethargy, irritability, tremors, poor feeding, temp instability, full anterior fontanelle -> EEG often abnormal early when CSF and neuroimaging normal
- Disseminated: multiple organs; often present in wk1 life with nonspecific signs of neonatal sepsis (temp dysregulation, apnea, irritability, lethargy, resp distress, abdo distention, ascites) -> mortality (untx) >8%
ddx- bacterial sepsis, meningitis, pneumonitis, hepatitis, other viral
ix - culture positive HSV, HSV DNA PCR, HSV antigens (rapid direct immunofluorescence/ enzyme immunoassays)
- if CNS neonatal HSV -> EEG, LP, neuroimaging
negative doesn't exclude
rx- empirical tx with acyclovir
168
What is roseola infantum: HHV6?
```
Baby measles
- high fever then 3-5d later generalized maculopapular rash spreading from trunk to extremities, sparing face (note fever subsides by time rash begins)
transmission- likely droplet
peak incidence 6-24mo
incubation period: 9-10d
rx- supportive
```
169
What are tinea infections?
- can infect head (capitus), body (corporis), feet (pedis), face (faciei), groin (cruris)
- many microorganisms - often Tinea family
5 clinical patterns tinea capitis
- diffuse scaling
- circumscribed alopecia with scale
- black dots (broken hairs)
- kerion (boggy mass)
- pustular
dx -scraping for KOH and fungal culture
rx
- tinea capitis: systemic tx with oral terbinafine x4wk
- other types = topical bid with terbinafine, ciclopirox, clotrimazole, ketoconazole for up to 4wk
170
Ddx diaper rash
- irritant contact dermatitis (shiny red macules, patches)
- seborrheic dermatitis (cradle cap) (yellow greasy plaques)
- candida (beefy red patches, peripheral scales)
- psoriasis (well demarcated papules/ plaques)
- bullous impetigo (bullae on erythematous base)
- Langerhans cell histiocytosis (hemorrhagic papule or plaques)
- Acrodermatitis enteropathica (dermatitis , alopecia, diarrhea triad -> zinc deficiency)
171
What is most emergent abdominal pain in peds?
- midgut volvulus with malrotation
172
Define visceral (splanchnic) pain
- due to noxious stimuli (often stretch) stimulating receptors of visceral peritoneum, mesentery, or muscle or mucosa of hollow organs
- dull, poorly localized, associated with midline (due to afferent autonomic innervation)
173
Visceral pain is sensed in areas corresponding with what?
Epigastric pain?
Periumbillical pain?
Suprapubic/hypogastric pain?
- corresponding to embryonic origin of affected structure
epigastric -> foregut (esophagus to duodenum, liver, gallbladder, pancreas)
periumbillical -> midgut (distal 2nd part duodenum to proximal two-third of transverse colon)
suprapubic/hypogastric -> hindgut (distal third transverse colon to rectum)
174
Define parietal (somatic) pain
- noxious stimuli (stretch, inflammation/ irritation, tearing) stimulating receptors of parietal peritoneum, skin, or skeletal muscle
- intense, localized, on same side and dermatomal region as origin of pain (somatic afferent nerves numerous, myelinated and transmit to specific dorsal root ganglion)
175
Define referred pain
- due to convergence/ shared projections of somatic and/or visceral pain pathways in CNS
176
Red flags abdo pain for organic pathology
- pain: progressive, localized (non umbilical), wake from sleep, radiates to shoulder/back/groin
- GI sx: dysphagia/ odynophagia, anorexia, emesis (bilious, bloody, persistent), jaundice, no flatulus/bowel movement, diarrhea (chronic, nocturnal), hemtochezia/ melena
- extraGI sx: unexplained fever, wt loss/ FTT, decelerated linear growth velocity, oral ulcers, perirectal disease, arthritis, cough/ dyspnea, dysuria/ hematuria, vaginal d/c or bleeding, scrotal/ pelvic pain
fhx: IBD, celiac disease, peptic ulcer disease
177
Diagnosis?
- delayed meconium
- FTT
- bilious vomiting
- chronic constipation since birth
o/e - abdo distention
DRE: tight anal sphincter, empty ampulla, blast sign (expulsion gas and stool after DRE)
--> further investigations?
Hirschsprung disease
Inv
- barium enema: narrow/ normal rectum, dilated colon proximal to ganglionic segment, with transition zone
definitive dx by rectal biopsy - absence of ganglion cells
178
Diagnosis?
- sx onset 3-8wk old
- FTT, "hungry vomiter"
- M>F
- projectile, non bilious vomiting, immediately postprandial
o/e: +/- visible peristalsis
possible palpable epigastric mass (olive sign)
-> further investigations?
Pyloric stenosis
Inv
- U/S: hypertrophied pylorus (increased muscle thickness and length)
- lytes/blood gas: hypochloremic, hypokalemic metabolic alkalosis
179
Diagnosis?
- bilious vomiting within hours of birth (later if stenosis)
o/e: epigastric distention, 1/4 have trisomy 21
-> investigations?
Duodenal atresia
Inv
- AXR: double bubble sign, absent distal abdo gas
Upper GI series: duodenal obstruction (UGI suggested preoperatively to r/o malrotation with midgut volvulus)
180
Diagnosis?
- unexplained paroxysms of irritability, fussiness, crying starting/stopping without obvious cause
- <4mo old, no FTT
- episodes >3hr/d, >3d/wk, for >1wk
o/e healthy infant
-> investigations?
Infantile colic
Inv
- clinical dx with Rome III criteria
181
Rome III Criteria for functional chronic abdo pain disorders
- all functional disorders -> no evidence of inflammatory, anatomic, metabolic, or neoplastic process to otherwise explain sx
- functional dyspepsia: persistent/ recurrent upper abdo pain or discomfort >1x/wk for >2mo
- IBS: abdo pain/discomfort with >2/3 (pain improved by defecation, associated with change in frequency of stool or form of stool) for >25% time, >1x/wk for >2mo
- childhood functional abdo pain: episodic/ continuous abdo pain, >1x/wk for >2mo
- childhood functional abdo pain syndrome: functional abdo pain >25% time with some loss of daily activity, headache, limb pain, or difficulty sleeping
- abdo migraine: intense periumbillical pain for >1h, interferes with normal activities, associated with >2 of 6 (headache, photophobia, nausea, vomiting, pallor, anorexia), intervening usual health
- recurrent abdo pain (Rome II): >3 episodes of pain severe enough to affect daily activities >3mo
182
Diagnosis?
- regurgitation/ emesis, feeding aversion, colicky baby, irritable
- apnea, stridor, aspiration, wheeze
- Sandifer syndrome
o/e +/- FTT
+/- hoarseness, stridor, wheeze
-> investigations
GER/ GERD
note: FTT in GERD
Inv
- empiric trial of acid suppressant
- endoscopy: esophagitis
24h pH probe/impedance study: acidic/ non-acidic reflux, strength of association with suspected signs/ symptoms
+/- upper GI series: r/o obstruction, stenosis, malrotation
183
What is Sandifer syndrome?
- back arching
- chin lifting
- neck contortions
- > due to discomfort with GER(D)
184
Diagnosis?
- classic hx = swelling in inguinal area during crying/ straining
- irritable, crying, vomiting, abdo distention, groin pain
o/e firm, tender, often oedematous inguinal mass
+/- surrounding erythema
+/- abdo distension/ tenderness
+/- scrotum appears blue (testicular venous congestion)
-> investigations?
Incarcerated inguinal hernia
Inv
- clinical dx
- AXR (may see lower GI obstruction or air bubble in groin)
U/S
185
Diagnosis?
- 3mo - 3yr (up to 6yo)
- paroxysmal, severe, crampy abdo pain, inconsolable crying, drawing up legs
- episodes progress in frequency
+/- vomiting
- currant jelly stool (blood, mucous)
- initially comfortable/normal behaviour between episodes, progressive lethargy
o/e: abdo pain may be benign vs. variable abdo distension and tenderness
+/- palpable sausage-shaped RUQ or epigastric mass
+/- bloody mucus on DRE
-> investigations?
Intussusception
Inv
- air contrast enema: obstruction (filling defect), air fluid levels, absence of gas in RLQ
U/S: target sign (bowel within bowel), tubular mass
186
Diagnosis?
- sudden onset bilious emesis, abdo distension, melena
- septic shock (necrotic bowel and 3rd spacing)
- children may have episodic abdo pain with vomiting for weeks to years before detection
o/e: abdo distension/tenderness
+/- peritonitis/ shock
-> investigations?
Malrotation with mid-gut volvulus
Inv
- AXR: upper GI obstruction (dilated proximal loops with fairly gasless abdo), pneumoperitoneum
- Upper GI series: failure of duodenum to cross midline (malrotation), duodenal obstruction (volvulus)
187
Diagnosis?
- dysuria, urgency, frequency
- irritability, fever, poor feeding
- vomiting/diarrhea
- flank/abdo pain
o/e: tend abdo (suprapubic)
+/- CVA tenderness - Murphy punch sign
+/- fever
-> investigations?
UTI
- Murphy punch sign with pyelonephritis
Inv
- urine R&M (WBC, nitrites, leukocyte esterase), C&S
- controversy in workup after 1st UTI: renal US +/- VCUG
188
```
Diagnosis?
- BMs 2 or less per week, large diameter, difficult/ incomplete evacuation
- colicky abdo pain, painful defacation
+/- encopresis
+/- retentive posturing
```
o/e: abdo palpation of hard fecal mass
- dilated rectum filled with stool
+/-anal fissure
-> investigations?
Constipation
Inv
- clinical (Rome criteria for functional constipation)
- AXR: fecal impaction (excessive stool in colon)
189
Diagnosis?
- fever, cramping abdo pain
- diarrhea +/- BRBPR
- vomiting, anorexia
- H/A, myalgia
o/e soft, tender abdo
+/- fever
-> investigations?
Gastroenteritis
- 70-80% viral
- 10-20% bacterial
- 5% parasitic
Inv
- stool C&S, stool O&P, stool C. difficile PCR
(only send if bloody or chronic diarrhea, immunosuppressed, recent abx use, exposures to bacterial/ parasitic disease)
190
Diagnosis?
- resp tract sx
- n/v
- chest and/or upper abdo pain
o/e: tachypnea, hypoxia, increased WOB, fever
- percussion dullness, increased tactile fremitus, decreased air entry, bronchial breath sounds
-> investigations?
Pneumonia
Inv
- CXR: focal consolidation, pleural effusion (atypical pneumonia with patchy diffuse opacifications)
+/- increased WBC
191
Diagnosis?
- preceding gastroenteritis, fever, bloody diarrhea (5-10d)
- abrupt onset of irritability, lethargy, deem, pallor (usually without purpura)
o/e: toxic +/- uremic encephalopathy
- tender abdo
- HTN
-> investigations?
HUS
(E. coli O157:H7, Shigella)
```
Inv
- CBCD, blood smear, haptoglobin and bilirubin: MAHA, thrombocytopenia
Cr: increased (ARF)
u/a: proteinuria, hematuria
stool C&S: infection
```
192
Diagnosis?
- colicky abdo pain with vomiting (within 8d purpuric rash)
- melena/ hematochezia
- arthralgias
- hematuria
- rare GI complications: intussusception, pancreatitis, protein-losing enteropathy
o/e: palpable purpura on lower extremities/ gravity dependent areas
- oligoarthritis
+/- HTN
-> investigations?
Henoch-Schonlein Purpura (HSP)
Inv
- no lab findings dx
common: increased ESR, CRP, WBC, platelets; anemia
IgA: elevated 50-70%
INR/PTT: no coagulopathy
+/- hematuria, proteinuria, increased Cr
biopsy skin/kidney (rare); IgA deposition, leukocytoclastic vasculitis
193
Diagnosis?
- colicky abdo/flank pain, radiating to testes or labia
- n/v, chills, ileus
- gross hematuria, dysuria, urgency
o/e: fever
abdo +/- CVA tenderness
-> investigations?
Urolithiasis
Inv
- radiopaque stones on AXR
Non-contrast CT gold standard
- u/s: obstruction of GU system, hydronephrosis
194
Diagnosis?
- n/v, anorexia
- dehydration, wt loss
- fatigue
- polyuria, polydipsia, polyphasic
o/e dehydration, diffuse abdo tenderness, Kussmaul breathing
-> investigations?
DKA
Inv
- increased blood glucose (>11.1 mM)
- ABG: WAG metabolic acidosis (HCO3 <15, pH <7.3)
- positive urine/serum ketones
+/- increased WBC, Cr, BUN (hemoconcentration)
195
Diagnosis?
- periumbilical pain migrating to RLQ (worse with cough, walking, jumping)
- anorexia, n/v
o/e: fever
RLQ tenderness (percussion and palpation), often focal at McBurney point
+/- peritonitis: rebound tenderness, involuntary guarding, Rovsign sign, Obtruator sign, iliopsoas sign
-> investigations?
Appendicitis
Inv
- US: thick walled/dilated appendix +/- appendicolith
- CT: enlarged appendix, appendicolith, associated mesenteric fat stranding
+/- increased WBC, increased neutrophils
196
Diagnosis?
- severe persistent epigastric/ LUQ pain radiating to back, alleviated by bending forward
- anorexia, vomiting
- restlessness, agitation
o/e
- fever, tachycardia
- tender +/- distended abdo
- periumbilical or flank bruising (hemorrhage) - rare in peds
-> investigations?
Pancreatitis
Inv
- increased lipase, increased WBC
- u/s: hypo echoic enlarged pancreas +/- gallstones
- CT: deem, necrosis, hemorrhage, peripancreatic fat stranding, pseudocyst
197
Diagnosis?
- epigastric/ RUQ pain, steady, severe +/- radiation to shoulder or back, worse with motion
- preceded by/ associated with fatty meal
- anorexia, n/v
o/e: fever, tachycardia
- tender abdo +/- guarding +/- Murphy sign
-> investigations?
Cholecystitis
Inv
- US: thick wall, gallstones, dilated gallbladder
- increased WBC
- bilirubin, ALP, GGT usually normal
- HIDA: non visualized gallbladder
198
Diagnosis?
- FTT/wt loss, fatigue, growth failure, pubertal delay
- red eyes, mouth ulcers
- abdo pain
- perianal disease
- diarrhea +/- blood, mucous/pus, urgency, tenesmus
- arthralgia, rashes
o/e - tender abdo +/- RLQ mass
- extraGI: fever, episcleritis, oral ulcers, pallor, digital clubbing, erythema nodosum, pyoderma gangrenous, arthritis/ scroilitis, perianal disease
-> investigations?
IBD
Inv
- anemia (iron deficient and chronic inflammation)
- increased WBC and platelets, increased ESR/CRP
- low albumin, vit D
- stool + blood, WBC
- upper endoscopy/ colonoscopy, small bowel imaging
199
Diagnosis?
- severe sudden onset testicular or scrotal pain +/- inguinal/ lower abdo pain
- n/v +/- fever
o/e: tender, swollen testicle
- elevated +/- horizontal lie
- absent ipsilateral cremasteric reflex
-> investigations?
Testicular torsion
Inv
- Scrotal doppler US: compromised testicular perfusion
200
Diagnosis?
- sexually active
- missed period
- vag bleeding, pelvic pain
o/e: painful internal pelvic exam +/- peritonitis
-> investigations?
Ectopic pregnancy
Inv
- increased serum b-hCG (slow rise)
- pelvic US: absent intrauterine fetus +/- visible ectopic pregnancy
201
```
Diagnosis?
- dysmenorrhea
+/- acyclic pelvic pain
- abnormal vag bleeding
- urgency, dysuria, dyschezia, constipation
```
o/e: general pelvic tenderness
+/- tender uterosacral ligaments, posterior uterus
+/- fixed uterine retroversion
-> investigations?
Endometriosis
Inv
- pregnancy test -
- pelvic US: excludes other pathology, may see endometrioma
- laparoscopy
202
Diagnosis?
- sudden unilateral abdo/pelvic pain +/- n/v
o/e: painful unilateral adnexa +/- peritonitis
-> investigations?
Ovarian torsion
Inv
- pregnancy test negative
- pelvic US: ovarian torsion
203
What is Pediatric Appendicitis Score (PAS)?
1 point:
- anorexia
- n/v
- migration of pain
- fever >38.5
- WBC >10 x10^6/L
- neutrophils + band forms >7.5 x 10^6 cells/L
2 points:
- RLQ tenderness
- pain with cough/percussion
PAS <2 = low risk
PAS 3 - 6 = intermediate risk -> consider surgical consult, serial exams
PAS >=7 = high risk -> surgical consult
204
HUS triad
- acute kidney injury
- thrombocytopenia
- microangiopathic hemolytic anemia
205
DKA precipitants?
- insulin deficiency (new dx or missed insulin dose)
- infection
- ischemia
- intoxication
206
Ladd procedure for what?
Malrotation with midgut volvulus
207
Define diarrhea? Acute vs. chronic?
- increased frequency, fluidity, volume of stools
WHO - unusually loose or watery stools, at least 3x/d
- acute = <2-3wk
- chronic = >2-3wk
208
How many L can colon absorb?
3-5 L/d
209
Pathophysilogic mechanisms of diarrhea?
Osmotic - ingested, non absorbed solutes reach colon, creating osmotic gradient that allows water diffusion into lumen (e.g. lactase deficiency)
Secretory - excessive secretion of lytes (esp. Cl via CFTR) into lumen after noxious stimulus, with water following (e.g. bacterial toxin)
Altered motility - increased motility results in reduced transit time for water absorption (e.g. ileocecal valve resection)
Inflammation - multifactorial: damage/atrophy of vili, epithelial cell dysfunction (altered fluid/electrolyte transport) and increased motility and secretions (infection, IBD)
210
Ddx acute abdo with diarrhea?
- intussusception
- appendicitis
- toxic megacolon
- evolving bowel obstruction
211
Blood/ mucous diarrhea likely?
Inflammatory diarrhea
212
Acholic diarrhea likely?
cholestasis
213
Foaming/ floating/ greasy/ foul smell diarrhea likely?
Steatorrhea - 80% pancreatic insufficiency, 12-15% mucosal disease
214
Watery diarrhea likely?
malabsorption, secretory
215
Undigested particles in diarrhea likely?
toddler's dirrhea
216
Small volume leakage/ incontinence likely?
Consider constipation
217
Risk of what GI condition with asthma/ allergic disease?
eosinophilic gastroenteritis
218
Red flags diarrhea?
- severe continuous or nocturnal diarrhea
- systemic sx: fever, rash, arthritis
- blood or mucous in stool
- very acidic stools
- weight loss/ FTT
- petechiae or purpura
- signs dehydration
- change mental status
- severe abdo pain or distension
219
Stool assessment for inflammation?
- fecal WBC +/- calprotectin
220
When do you do stool pH and electrolytes?
Watery stools
- osmotic vs. secretory diarrhea
osmotic pH <5, osmotic gap >125 mM, Na <60 mM
secretory pH >5, osmotic gap <50 mM, Na >90 mM
221
Workup suspected carbohydrate maldigestion/ malabsorption?
- stool for reducing substances
| - lactose hydrogen breath test
222
Steatorrhea workup?
- tests of malabsorption: stool microscopy for fat globules, quantitative 72h fecal fat collection
- screen cholestasis: bilirubin (total/direct), GGT, ALP, vitamin A, D, E, INR, triglycerides, cholesterol
- screen pancreatic insufficiency: fecal elastase, sweat chloride
223
Workup suspected protein-losing enteropathy?
- stool alpha-1-antitrypsin
| - calcium, INR, albumin
224
What etiologies of diarrhea increase immunoglobulin (IgE)?
- suspected immunodeficiency or eosinophilic gastroenteritis
225
Stool osmotic gap
- estimates relative contributions of electrolytes and non electrolytes to retention of water in intestinal lumen
- normal stool osmolarity is 290 mmol/L (isotonic to plasma)
- stool Na and K in stool multiplied by 2 in equation to account for obligate anions
- stool osmotic gap (mmol/L) = 290 (or measured stool osmolarity) - 2 (stool [Na] + stool [K])
226
What supplementation can reduce duration and severity of diarrhea?
Zinc
227
Can antibiotics increase the risk of hemolytic ureic syndrome in patients with E. coli O157-H7?
Yes
228
What is fecal impaction?
- hard mass in lower abdo on exam, dilated rectum with large amount of stool on rectal exam, or excessive stool in distal colon on abdo xray
229
What is encopresis?
- recurrent, episodic fecal incontinence (involuntary loss of stool into child's underwear, after reaching developmental age of 4yr) due to overflow of stool caused by fecal impaction
230
Phases of normal defecation?
- involuntary phase: normal colonic transit delivering fecal material to rectum
- voluntary phase: leading to expulsion of stool
231
What nervous system(s) input to control colonic and rectal motor function?
- enteric NS
| - autonomic NS
232
What is vast majority of functional constipation secondary to?
- purposeful/ subconscious stool withholding
- > pushes stool higher into rectum (diminishing urge to defecate)
- > colon absorbs water and electrolytes from retained stool, with increasingly larger stool volume with harder consistency
233
Results of chronic rectal distension?
- decreased rectal sensitivity and loss of normal urge to defecate
234
Rome III diagnostic criteria for functional constipation
In absence of organic pathology and >=2 of:
Neonates/toddlers (<4yr)
- <=2 defections/wk
- >=1 episode fecal incontinence/wk after acquiring toileting skills
- excessive stool retention
- painful/hard bowel mvoements
- large diameter stools that may obstruct toilet
- large fecal mass in rectum
for >=1mo
Kids/adolescents (>=4yr)
- <= defecations in toilet/wk
- >=1 episode fecal incontinence/wk after toileting skills
- retentive posturing or excessive volitional stool retention
- painful/hard BM
- large diameter stools, may obstruct toilet
- large fecal mass in rectum
for >=1x/wk, >=2mo
235
Anal fissures with functional constipation of HD?
- more common in functional constipation
236
Red flags on physical exam in child with constipation to suggest organic etiology?
- severe abdo distention
- abnormal abdo musculature
- abnormal anal position (e.g. anteriorly displaced)
- perianal fistula
- anal scars, hematoma, or extreme fear during anal inspection
- tight, empty rectum with palpable abdo fecal mass
- explosive stool and air from rectum after withdrawal of examining finger (blast sign)
- midline pigmentary abnormalities of lower spine
- sacral dimple and/or overlying tuft of hair
- gluteal cleft deviation, flat buttocks
- absent anal reflex (anal wink) or cremasteric reflex
- decreased strength/tone/deep tendon reflexes in lower extremities
237
Lab tests requiring further evaluation in kid with constipation?
- electrolytes, calcium, TSH, T4, celiac screen (+/- lead levels, sweat chloride)
238
What needs to be ruled out with intractable constipation (no response to tx >3mo but normal lab tests)?
Hirschsprung disease
- anorectal manometry
- rectal biopsy (gold standard)
Anatomical malformations
- barium enema
+/- cows milk protein allergy
- 2-4wk trial of cow milk protein avoidance
- allergy testing not routinely done
+/- spinal cord malformation/anomalies
- MRI spine not routinely supported without neurologic or lumbosacral abnormalities
239
First line tx for constipation (medication)?
PEG
maintenance PEG or lactulose
240
Definition of FTT
- weight that falls or remains below the third percentile for age; decreases and crosses 2 percentile lines or is less than 80% median weight for height
- can be associated with short stature
241
How long to do correct for prematurity in preterm infants?
Up to 24mo age
242
Investigations FTT pre/perinatal causes
- TORCH screen, HIV if appropriate
- genetic consultation; chromosomal and molecular genetic testing
- cranial US
243
Investigations FTT feeding issues
- three day dietary record
- lactation consult (infants: latch, suck, swallow)
- dietician and OT-observed feeds
244
Investigations FTT malabsorption/ ultilization
- CBCD
- protein, albumin, bilirubin, LFTs, coagulation factors (INR)
- iron, ferritin
- inflammatory markers (ESR, CRP)
- anti-TTG, IgA
- stool for lipid globules, reducing subtances
- sweat chloride, SaO2, sleep study
- upper GI series (imaging)
245
Investigations FTT increased demands
- metabolic: metabolic screen, serum and urine amino acids, molecular genetic testing
- renal failure: urinalysis, creatinine, electrolytes
- infections: HIV/ other viral serology, stool cultures, immunoglobulins
- congenital heart disease: associated clinical findings and cardiac imaging
- respiratory: sweat chloride
- endocrine: low TSH, high FT4, glucose, insulin tolerance test (for GH deficiency), bone age
246
Pattern I growth parameters with FTT
- HC: normal
- Ht: normal or low
- Wt: low, low for height
- Appearance: malnourished
- Etiologies - multiple
247
Pattern II growth parameters with FTT
- HC: normal
- Ht: low
- Wt: low, proportional to height
- Appearance: healthy
- Etiologies: endocrinopathy, dwarfism, constitutional deprivation, normal variant short stature (not true FTT)
248
Pattern III growth parameters with FTT
- HC: low
- Ht: low
- Wt: low, proportional height
- Appearance: stunted
- Etiologies: early onset = IUGR, chromosomal/ genetic abnormality, perinatal insults
249
Define limp
- uneven or jerky walk, due to pain, weakness or deformity (structural abnormality of bones, joints, soft tissues, or nerves of lower extremities, pelvis or spine)
250
What is the inner tissue layer lining a joint, which secretes synovial fluid to lubricate the joint?
Synovial membrane
| - fluid can become inflamed or infected and cause sx pain and swelling
251
Diagnose: self-limiting, nonspecific inflammation of synovial membrane
Transient synovitis
| - most common cause of paediatric non traumatic hip pain
252
What dx must be ruled out with limp/ joint pain?
- septic arthritis -> synovial fluid analysis and culture
| often child with limp has fever and is toxic appearing
253
What presents as recurrent, self-limited, and usually bilateral leg pain; common in preschool and school aged kids?
Growing pains
254
Systems re: causal conditions of child with limp/ pain?
- bones (osseous)
- joints (articular)
- soft tissue
- neurologic
- other
255
Age group for DDH?
- preschool age
256
Age group for Legg-Calve-Perthes disease, leukaemia, osteosarcoma?
- school aged
257
Age group for Osgood-Schlatters disease, slipped capital femoral epiphysis, over-use injuries
- adolescents
258
Abnormal leg length discrepancy?
>1.25cm
259
First line investigations for kid with limp?
- x-ray
260
What will U/S detect in kid with limp?
DDH <3mo
small joint effusions
US-guided joint aspiration
261
Lab workup kid with limp?
CBC
ESR
CRP
blood cultures if sepsis suspected
- synovial fluid analysis - for inflammatory and infectious conditions
262
What is chronological delay in appearance of set developmental milestones achieved during infancy and early childhood?
Developmental delay
| - causes: organic, psychological and environmental factors (cause of developmental lag often unknown)
263
Define global developmental delay
- developmental delay in >2 areas during infancy or preschool years
264
What are the developmental milestones?
- gross motor
- fine motor
- language
- social
265
Age of:
Gross motor: raises head slightly, hands fisted, primitive reflexes
Fine motor: tight grasp, follows to midline
Language: alerts to sound
Social: regards face, responds positively to feeding
Newborn
266
Age of:
Gross motor: holds head to midline, lift chest, supports on forearms
Fine motor: tracks past midline, waves at toys
Language: searches for sound with eyes, coos
Social: recognizes parents, social smile, moves arms actively to stimulus, anticipates feeds
2-3mo
267
Age of:
Gross motor: rolls front-back/ back-front, sits when propped, supports on wrists
Fine motor: moves arms in unison to grasp objects
Language: orients to voice, makes razzing sounds
Social: hard regard, enjoys looking at environment, reaches out for toys, laughs
4-5mo
268
Age of:
Gross motor: sits unsupported, feet to mouth while supine
Fine motor: reaches with one hand, transfers, raking grasp
Language: babbles, responds to name, indiscriminate dada/mama
Social: recognizes strangers, looks toward person talking to them
6-8mo
269
Age of:
Gross motor: creeps, crawls, cruises, pulls to stand
Fine motor: pincer grasp, probes with forefinger, holds bottle
Language: understands 'no', waves, discriminant dada/ mama
Social: explores environment, object permanence
8-12mo
270
Age of:
Gross motor: walks alone, creeps upstairs
Fine motor: throws objects, scribbles in imitation, builds 2-4 block tower
Language: uses 2 words, runs, unintelligible words together
Social: imitates, comes when called, cooperates with dressing, indicates wants
12-18mo
271
Age of:
Gross motor: runs, throws toys, kicks balls, walks upstairs
Fine motor: turns 2 pages at a time, spoon feeds self, builds 4-6 block tower
Language: knows 8 body parts, uses intelligible words in margining, >20words
Social: copies tasks, plays along-side other kids, seeks approval
18-24mo
272
Age of:
Gross motor: walks up + down stairs, overhand throw
Fine motor: turns pages one per time, removes clothes, holds pencil
Language: >50 words and 2word sentences, 25% intelligible
Social: parallel play, imaginary play, gender aware
2-3yr
273
Age of:
Gross motor: pedals tricycle, alternates feet upstairs
Fine motor: dresses and undresses partially, copies circles
Language: 3-word sentences, minimum 250 words, knows own name, 75% intelligible
Social: group play, shares toys
3yr
274
Age of:
Gross motor: hops, skips
Fine motor: buttons, catches ball, copies square
Language: colours, asks Q, prints first name
Social: tells tales, plays cooperatively
4yr
275
Age of:
Gross motor: skips alternating feet, jumps over obstacles
Fine motor: ties shoes, copies triangle
Language: prints first name
Social: plays competitive games, follows rules
5yr
276
Ddx developmental delay and short stature
- malnutrition
- Williams syndrome
- Turner syndrome
277
Ddx developmental delay and obesity
- Prader-Willi syndrome
278
Ddx developmental delay and microcephaly/ macrocephaly
- micro: condition retarding brain growth
| - macro: Sotos syndrome, hydrocephalus, mucopolysaccharidoses
279
Ddx developmental delay and facial dysmorphism
- fetal alcohol syndrome
- trisomies
- cri du chat
280
Ddx developmental delay and skin lesions (cafe au last spots, Shagreen patches, port-wine stains)
- neurofibromatosis
- tuberous sclerosis
- Sturge-Weber syndrome
281
Ddx developmental delay and abnormal tone/ ataxia
- hypertonic: cerebral palsy, neurodegenerative
| - hypotonic: Prader-Willi, Down, Angelman syndromes
282
Ddx developmental delay and joint contractors (sign of muscle imbalance around joints)
- arthrogryposis cerebral palsy, muscular dystrophy
283
Ddx developmental delay and size of genitalia
- macro-orchidism= Fragile X syndrome
| - hypogenatalism = Prader-Willi/ Klinefelter syndrome, CHARGE associated
284
First line testing and lab investigations with developmental delay
- full history/ physical
- formal developmental assessment
- formal hearing and vision assessment
- if diagnosis not apparent, consider investigations
Inv
- CBC, ferritin, vit B12
- urea, electrolytes, creatine kinase
- lead levels
- TSH
- urine metabolic screen
- molecular karyotype
285
What is a transient clinical expression of abnormal, excessive, synchronous discharges of cortical neurons?
Seizure
286
Define epilepsy
- chronic disorder characterized by recurrent seizure episodes that are unprovoked in nature; may be due to syndromes or cryptogenic in nature
287
What is status epilepticus?
- ongoing seizure activity for >30 min or repetitive seizure activity without return of consciousness for >30min
288
What can happen to neurons after 30min seizure activity?
- ischemic and excitotoxic neuronal cell loss
289
What is a psychogenic non epileptic seizure (pseudo- seizure)?
- emotional or stress-related in origin; often involuntary
290
Provoked seizure types?
- benign suzire occurring in kids 6mo - 6yr, associated with temp >38
- intercurrent illness
- metabolic derangement/withdrawal
- hemorrhagic/ ischemic stroke
291
Classification of generalized seizures
Generalized (initial neuronal activation of both hemispheres)
- generalized tonic-clonic (GTC) - most common; still limbs for 10-30sec then rapid jerking of limbs and trunk
- tonic - sustained muscle contraction, high-pitched cry, <60 sec
- clonic - rhythmic, symmetrical contractions of groups of muscles, prologned
- atonic - sudden loss of muscle tone, <1-2sec
- myoclonic - sudden, brief (<100 sec) involuntary muscle contractions; generalized or focal; single or repetitive; rhythmic or irregular
- absence (staring spells) - abrupt cessation of activity with maintenance of tone, <30sec, no postictal state
292
Classification of partial seizures
Partial (initial activation of neurons limited to part of one hemisphere)
- simple motor - activation of cerebral cortex, may see Jacksonian march; tongue, lips, hands commonly involved
- simple sensory - activation of sensory cortex; numbness or dysesthesias in any body part; abnormal proprioception
- simple autonomic - activation of central autonomic network; epigastric sensation, sweating, dilated pupils
- complex partial - any of above partial seizure subtypes + LOC
293
What is atypical febrile seizure?
- generalized seizure lasting >15min, focal feature or postictal paresis; occurring in series with total duration >30 min
294
Features suggestive of seizure?
- aura
- identifiable triggers
- altered breathing
- cyanosis
- incontinence
- tongue-biting
- prolonged postictal drowsiness
- confusion amnesia
- transient focal paralysis (Todds)
295
Management seizure
- ABCs, O2
- O2 sat and cardiac monitor
- establish IV
rapid glucose, critical labs (Na, Ca, Mg, etc), CBC/ blood culture, toxicology screen, serum AED levels
5 min:
- SL/PR/IV Lorazepam
- or IV/ PR diazepam or IM midazolam
- > repeat x1 if no control in 5min
give dextrose in first 10min (empirical or hypoglycaemic)
15min from start seizure:
- IV Fosphenytoin or IV phenytoin
20 min from start seizure:
- incubation prep
- IV/IM phenobarbital
+/- PR paradelehyde
30 min from start seizure:
- rapid sequence intubation
- PICU for continuous AED (anti-epileptic drug) infusion
296
Rx carbamazepine or oxcarbazepine for what type seizure?
focal (partial)
297
Rx valproate for what type of seizure?
generalized seizure
298
Rx ethosuximide, valproic acid for what type of seizure?
childhood absence epilepsy
299
Rx valproate, lamotrigine for what type of seizure?
juvenile myoclonic epilepsy
300
Rx vigabatrin. ACTH for what type of seizure?
infantile spasms
301
Rx valproate for what type of seizure?
unclassified epilepsy
302
Define paediatric HTN
- sustained elevation (on 3 separate occasions) of sBP or dBP >95th percentile for age, height, gender
303
Equation for BP
BP = CO x SVR
304
RAAS pathway
- renin secreted by juxtaglomerular cells --> angiotensinogen to angiotensin I
- -> angiotensin I --> angiotensin II via ACE
- > angiotensin II = vasoconstriction of blood vessels (increase BP) and release of aldosterone (increase Na and H2O absorption)
305
BP cuff
- length = >80% circumference mid-upper arm
| - width = >40% circumference mid-upper arm
306
Classic triad pheochromocytoma
- episode headache, diaphoresis, palpitations
307
Assume child has primary HTN?
NO! Always do workup for secondary causes
308
Investigations for kid with HTN
- CBC, lytes, BUN, Cr
+/- steroid levels, metanephrines
- fasting labs: lipid levels, glucose
- urine: urinalysis (R&M, C&S), b-hCG
+/- urine toxicology if illicit drug use
- imaging: abdo u/s re: kidneys, renal vasculature, genitourinary system
+/- CXR, ECHO
- sleep study re: OSA
- ABPM x24h >5yr if considering white coat HTN
309
When to treat paediatric HTN with pharmacological meds?
- lifestyle x6mo but persistent HTN
- ACEI if kid has DM and microalbuminuria or proteinuria renal disease
- first line: ACEI, CCB, B-blockers, diuretics, ARBs
310
Management HTN emergencies in kids?
- acute symptomatic HTN
- goal: initial reduction of sBP by 20%
- > Nifedipine PO
- continues HTN = hydrazine IV/IO
- malignant HTN - consider ICU admission
- > Labetalol IV; Nitroprusside infusion
311
How does brain signal gonadal production of sex hormones?
HPG axis -> estrogen, progesterone, testosterone
312
Gonadotropins?
FSH, LH
313
Is GnRH constant or pulsatile secretion? Starting when? Results?
Pulsatile during sleep
- beginning 1-3yr prior to puberty (prepubertal stage)
- > increases LH to mature and enlarge gonads resulting in increased sex hormones and secondary sex characteristics
314
When does HPG axis assume normal activity?
Midpuberty = normal pulsatile activity and secondary sex characteristics further developed
315
Female secondary sex characteristics
- breast development (thelarche)
- increased body hair: pubic, axillary (adrenarche)
- widening hips, reduced waist-to-hip ratio
- change in fat distribution - increase SC fat around buttocks, thighs, hips
316
Male secondary sex characteristics
- increased facial, axillary, chest, underarm, pubic hair
- increased size of larynx and deepening of voice
- increase stature and muscle mass
- increased sweat glands and oil secretions causing acne and body odor
- enlargement of penis
317
Define precocious puberty
- onset secondary sex characteristics before age 8 (females) or 9 (males)
- females = 90% idiopathic
- males = 75% CNS abnormality
318
Ddx precocious puberty with increased FSH/LH levels
Gonadotropin dependent = central precocious puberty
- idiopathic (dx of expulsion)
- CNS tumor/lesion
319
Ddx precocious puberty with normal/decreased FSH/LH levels
Gonadotropin independent = peripheral precocious puberty
- adrenal
- gonadal
- normal variant
- hCG secreting tumor
- iatrogenic
320
Ddx delayed puberty with decreased FSH/LH levels
Gonadotropin dependent = central etiology
- constitutional delay
- hypothalamic dysfunction
- hypopituitarism
- hypothyroidism
- hyperprolactinemia
321
Ddx delayed puberty with increased FSH/LH levels
Gonadotropin independent = peripheral etiology
- Turner syndrome (XO)
- Kleinfelter syndrome (47 XXY)
- Bilateral gonadal failure
- Hormonal
322
What does bitemporal hemianopsia suggest?
pituitary tumor
323
Male <=9yo with testicle volume >3mL vs. <3mL +/- precocious puberty
- >3mL = central precocious puberty -> investigate
| - <3mL + features precocious puberty = adrenal or exogenous source of testosterone
324
Define delayed puberty
- sexual maturation not apparent by 13yr female or 14yr male
- absence of menarche by 16yr or within 5yr pubertal onset (females)
- m>f
- female more likely to have underlying pathology
- rule out overall growth failure
325
Likely dx with webbed neck, low set ears and high arched palate; widely spaced nipples, shield chest?
Turner syndrome
326
Cushing sx? Likely caused by?
- moon facies, dorcocervical fat pad; striae
| - > adrenal tumor
327
How do you score age of development in male and female secondary sexual characteristics?
Tanner staging
328
Investigations abnormal pubertal development
- serum FSH, LH
(increased in acquired gonadal failure by adolescence; if normal or decreased constitutional delay most common)
- estradiol (female), total testosterone (male)
- TSH
- GnRH test (ability pituitary to respond to GnRH)
- prolactin
- 17-OH-P based on clinical features
- CBC, ESR (chronic disease)
central etiology suspected: increased ICP sx = MRI or CT head
- bone age
- pelvic u/s
- adrenal u/s
- karyotyping if peripheral delayed puberty and clinical feature suggest chromosomal abnormality
329
What is bone age?
- degree of bone maturation (increase with increased sex steroid hormones)
- precocious puberty = bone age > chronological age
- delayed puberty = bone age < chronological age
330
Management central precocious puberty
- tx for full adult height potential
- GnRH analogs, GnRH agonist (Lupron) - turns off HPG by reducing GnRH receptors
- medroxyprogesterone slows breast and genital development
331
Management peripheral precocious puberty
- tx underlying cause
| - glucocorticoid replacement for CAH
332
Management central delayed puberty
constitutional delay
- reassurance
- hormonal therapy (estrogen, testosterone) to initiate puberty in some pt
hypogonadism
- lifelong sex steroid replacement
333
Management peripheral delayed puberty
- tx underlying cause
334
What is disorders of sex development (DSD)?
- diagnostic criteria that refers to atypical development of chromosomal, gonadal, or phenotypic sex
335
Normal sexual differentiation 5-9wk GA?
5wk GA = sexually indifferent
- XY = paired gonadal ridges, Wolffian and Mullerian ducts
- XX = paired gonadal ridges, Wolffian and Mullerian ducts
6wk
- XY = begin expressing SRY (sex-determining region chrm Y) -> initiates testis formation
- XX = SRY not expressed (no Y chrm)
7wk (biopotential gonadal formation)
- XY = testicular development begins; sertoli cells secrete MIS (Mullerian inhibiting substance, aka AMH or anti-Mullerian hormone) = Mullerian duct regression
and Leydig cells produce testosterone stabilizing Wolffian ducts and promoting development of epididymis, vas deferent, seminal vesicle
- XX = lack of MIS = Mullerian duct maturation into oviduct, uterus, cervix, upper vagina
and lack of testosterone = Wolffian duct regression
9 wk (sexually distinct external genitalia)
- XY = peripheral synthesis of DHT (dihydrotestosterone) --> differentiation and growth of male external genitalia
complete by 12-16wk
- XX = non-hormone dependent vaginal and urethral separation
complete by 12wk
336
Most common cause of ambiguous genitalia?
CAH - congenital adrenal hyperplasia
- adrenal insufficiency can be life-threatening
- often 21-hydroxylase deficiency (autosomal recessive CYP21A2 gene mutation)
= defective conversion of 17-OH-P to 11- deoxycortisol
= reduced cortisol synthesis -> increased ACTH -> adrenal stimulation
337
Classic CAH presentation?
- salt losing vs. non-salt losing
females = genital ambiguity
males = no genital ambiguity
-> FTT, dehydration, electrolyte abnormalities
= adrenal insufficiency in early infancy
vs. late onset = signs androgen excess
- childhood: non-salt losing in males = accelerated bone age, premature pubarche
- adolescents, adult females = hirsutism, acne, infertility, menstrual irregularity
- some kids remain asymptomatic
338
Investigations ambiguous genitalia?
- karyotype = establish chromosomal sex
- FISH to evaluate SRY gene
- r/o CAH = 17-hydroxyprogesterone (or less common types DHEA, androstenedione, testosterone)
- ACTH stimulation test, cortisol level (suspect adrenal involvement)
- 5-alpha reductase levels in undervirilized genetic male
- serum electrolytes if concern for salt-wasting CAH
imaging: US abdo and pelvis for gonads, uterus, vagina, enlarged adrenals (CAH)
339
Most common acquired vs. inherited bleeding disorders?
- acquired = ITP
| - inherited = hemophilia A (factor VIII deficiency)
340
Underlying medical condition ddx for child abuse?
- nutritional deficiency (vit K, C)
- infection (meningococcemia)
- inflammation (HSP, ITP)
- malignancy and thrombocytopenia
- genetic (coagulopathies, osteogenesis imperfecta)
341
Timeline for sexual assault kit?
within 72h of assault
