Pediatrics Flashcards
A 9 yr old boy is seen in the pediatrician’s office with a several days hx of mouth weakness. He reports that he had a viral URI about 2 weeks prior. Denies headache, fever, vomiting, constipation, or weakness. He has been a healthy child w/o serious previous illnesses. On PE vitals are normal, L mouth droops, L eye can’t close, and smile is asymetric. EOM and fundoscopic exams are normal. CV+pulm and abdominal exam are normal. Gait sensation and DTRs are normal. What is the most likely Dx?
Bell’s Palsy!
- An acute unilateral facial nerve palsy that begins ~2 wks after viral infxn. Causes are thought to be reactivation of herpes simplex or VZV or demylination through an autoimmune process or allergic inflammation. Tx is supportive and includes maitaining moisture to the affected eye to avoid keratitis. 85% of cases spontaneously resolve.
- Always inspect the forehead! A peripheral neuropathy like Bell’s palsy will affect the forehead whereas a central neuropathy will not affect the forehead due to dual innervation.
A 4 yo girl is seen for a 1 mo hx of limp and swollen right knee. Parents report that the child has had intermittent limping and a swollen right knee, but denies fever, bruising fatigue or weight loss. On PE vitals are T-98.5, P-90, RR-22, BP-100/62. Mucous membranes are moist and w/o lesions. CV+pulm exam is normal. The L knee is swollen, warm and has decreased range of motion. An ophthalmologic exam reveals gross findings. What is the most likely dx?
Juvenile ideopathic arthritis (JIA)!
-This dz asymetrically involves the large joints, especially the knee, and usually has no other sx. Morbidity may include chronic uveitis–>blindness. About 20% of girls with JIA have iridocyclitis or anterior uveitis as a complication. This eye disorder can develop without signs or sx so frequent screening slip lamp exams are required and Tx is with systemic steroids.
A 9 yo girl is seen in the office for following up after being admitted to the hospital for a 3 wk hx of fever and positive blood cultures due to S. aureus. The hospital demonstrated vegetations of the mitral valve. She is week 6/6 of a course of IV Abx. She denies fever, vomiting, headache, or change in behavior. PE shows T 98.5, P-105, RR-18, BP-95/59. Mucous membranes are moist and w/o lesions. CV+pulm exam is normal. Extremities are w/o edema or splinter hemorrhages. What future planning should be considered?
This patient will need Abx prophylaxis for dental procedures!
-This kid had a bacterial endocarditis. The AHA suggests ABX prophylaxis for anyone with prior hx of endocarditis, prosthetic valves, heart transplants, or severe/partially repaired congenital heart defects.
A 14 yo boy is seen in the office with a 14 day hx of rash. The first lesion began on the lower back and additional lesions developed a few days later. The rash is slightly pruritic, but denies fever, nausea, vomiting, headache, or MSK sx. Pt takes antihistamines for seasonal allergies. Vaccines are current. Doing well in school, plays football, denies sex alcohol or drugs. T-98.5, P-92, RR-16, BP-110/69. Mucous membranes are moist w/o lesions. CV+pulm exam is normal. GU exam is normal Tanner 4. The rash on the back and abdomen are slightly raised at the edges with a somewhat scaly appearance in the center. What is the most likely Dx?
Pityriasis Rosea!
-A benign condition that starts with a “herald patch” anywhere on the body that is a single round/oval lesion. 5-10 days later a more diffuse rash involving the upper extremities and trunk appears. These lesions are oval/round, slightly raised, and pink to brown in color covered in a fine scale with some central clearing possible. The rash may appear with a christmas tree pattern on the back. Often mistaken for tinea corporis and consideration for syphillis must be made. Rash lasts 2-12 weeks and can be pruritic. Tx is typically unnecessary but involves emollients and oral antihistamines as needed. Topical steroids may be useful in severe itching.
A 5 yo boy is seen in the ED with a 1 day hx of low grade fever, colicky abdominal pain and a rash. Mom says he has been in his normal good state of health when sx began. Reports no vomiting, diarrhea, sick contacts, recent illnesses or change in behavior. No PMH and vaccines are current. Pt is in kindergarten and has had no difficulties. T-100.5, P-101, RR-20, BP-100/58. Pt is alert awake and in no distress. Mucous membranes are moist w/o lesions. CV+pulm and abdominal exams are normal. Skin has diffuse erythematous maculopapular and petechial lesions on the buttocks and lower extremities. Labs:
Hgb-14, Hct-42, WBC-8000 w/ 60% segmented neutrophils, 1% bands, 39% lymphocytes, Platelets 135,000, Urinalysis shows 30 RBCs per field and 2+protein, stool is guaic+. What is the most likely mechanism of these findings?
IgA mediated vasculitis!
- The clinical presentation is of Henoch Schonlein purpura or anaphylacoid purpura, a generalized and acute vasculitis of unknown cause involving small blood vessels. The skin lesion (palpable purpura) is often accompanied by arthritis of the large joints, and GI sx. Colicky abdominal pain, vomiting, and melena are common. Renal involvement is the most potentially serious complication as it may lead to chronic nephritis. Lab studies are not diagnostic but may show normal or elevated platelets, complement, and IgA.
- Meningococcal infxn and lekemia should be in the ddx as they can both cause purpura but are unlikely in this well appearing child with normal vitals and labs.
A 6 yo boy is seen in the office for a well child visit. He has recently been bullied and teased at school because he has stooled his underwear almost daily for the past 3 months. He was toilet trained at 2 w/o difficulty but has developed episodes of soiling himself over the past 18 months stating “i didn’t know i had to go”. PMH is unremarkable and when alone denies any abuse or inappropriate touching. T-98.5, P-100, RR-19, BP-102/60. Mucous membranes are moist w/o lesions and pulm and CV exams are normal. Abdomen is soft and w/o hepatoosplenomegally, LLQ seems “full” but not tender. Anal sphincter tone appears lax and a small amount of stool is noted at the os and in the rectal vault. A plain radiograph of the abdomen shows a dilated stool filled colon. What is the most appropriate initial management?
Clear fecal impaction and short-term stool softener use!
-Encoparesis can be seen in chronic constipation and overflow incontinence (retentive encoparesis) and w/o constipation (nonretentive encopresis). Retentive is more common and is the cause of this kids problem. He is leaking liquid stool around a large fecal impaction. Tx is by clearing the fecal mass, maintaining soft stools with mineral oils or stool softeners for a short period and behavioral modification. Most kids grow out of this.
A 10 yo child is seen in the office for new onset bed wetting. He denies dysuria, fever, vomiting, headache, change in behavior, or new stressors in his life. PMH and social hx are insignificant. T-98.5, P-95, RR-18, BP 120/80. Length is 50th percentile but weight is >97th percentile. BMI is 26.6. Mucous membranes are moist w/o lesions. Skin around the neck is hyperpigmented and velvety in texture. CV, pulm, GU, and abdominal exams are normal. What lab finding would confirm the cause of his sx?
Fasting plasma glucose of >=126!
-This is an obese kid with acanthosis nigricans suggestive of diabetes. Criteria for diagnosing diabetes include a fasting glucose>=126, a 2 hr plasma glucose during and oral glucose tolerance test >=200, or sx of diabetes plus a random glucose >=200. The bed wetting is explained by increased liquid consumption due to the hyperosmolar state caused by hyperglycemia.
A 2 yr old child and his 3 month old sibling are seen in the ED for rash. Mom says the 2 yo has had the rash on his feet and ankles for 4 days and the 3 month old has had the rash on the head and neck for 4 days. Neither child has had fever vomiting travel or change in environment. The rashes appear as erythematous papular erruptions with evidence of excoriation. What is the best tx for this condition?
Permethrin!
-This is a description for scabies infection. Permethrin is a viable option to what is used in adults, gamma benzene hexachloride (lindane), which can cause neurotoxicity in kids via percutaneuous absorption.
An 8 hr old newborn in the normal newborn nursery develops tachypnea and increased work of breathing. He was born vaginally at term to a 22 yo primagravida. Mom had limited prenatal care but reports no complications. Apgar scores were 9 & 9 at 1 and 5. Resuscitation was dyring warming and stimulating. He passed stool and uring in the delivery room. He was placed on the breast the 1st hour and latched well. Mom is AB+, rubella immune, HIV-, and screen negative. T-95.8, P-180, RR-80, BP-70/40, O2 sat 89%. Nose has nasal flaring, and chest has subcostal and intercostal retractions, grunting, and rales. Labs show hgb 13, hct 39%, WBC 1000, neutrophils 30%, band forms 50%, lymphocytes 20%, and platelets 20000. Chest xray shows diffuse bilateral granular infiltrates. What is the most likely dx?
Group B strep pneumonia!
-This is a normal newborn who develops hypothermia, tachycardia, tachypnea, hypotension and respiratory distress. The rapid onset of sx, low WBC count with left shift and thrombocytopenia and CXR findings are typical of a patient with GBS pneumonia. Management should be rapid recognition, cardiorespiratory support and rapid initiation of Abx.
An infant is admitted to the normal newborn nursery. He was born vaginally at 38 weeks gestation to a 33 yo woman with limited prenatal care. Weight, height, and head circumference are less than 10th percentile. He is somewhat irritable with good tone and cry. He has strabismus, abnormal palmar creases, microcephaly, and a short nose. Echo shows VSD. What is the most likely mechanism for his condition?
In utero ethanol exposure!
Fetal alcohol syndrome is cause by in utero exposure to alcohol and findings include small for gestation birth, microcephally, small palpebral fissures, short nose, smooth philtrum, thin upper lip, ptosis, strabismus, microphthalmia, and CNS abnormalities to include mental retardation. Cardiac defects such as VSD are common.
The triage nurse receives a call from a new mother. Her newborn daughter has developed a mild fever and rash. Mom was diagnosed with varicella at a local urgent care center. She delivered the baby 7 days prior. Newborn is being breastfed only. She has been eating, stooling, and urinating w/o difficulty. T-98.5. What is the most appropriate next step in management?
Advise mom to continue regular well baby care for her newborn!
-Per CDC varicella immunoglobulin (VZIG) should be administered immediately after delivery if mom had onset 5 days prior to delivery and immediately after dx if mom’s chicken pox starts within 2 days of delivery. If exposure to a full term baby is after 2 days of life there apparently is no increased risk of serious complications than with older kids. Acyclovir may be used in severe varicella such as those with chronic pulm conditions, skin infections, or patients older than 12.
A term infant is born vaginally to a 28 yo W whose pregnancy was complicated by gestational diabetes. Delivery was complicated by marginal placental separation. Birth weight was 2900 g and Apgar scores were 8 and 9 at 1 and 5. At 12 hours of age baby is seen by the NP, and reports normal feeding with one void recorded. T-98.6, P-140, RR-28. Head is normocephalic with flat fontanel. Cardiopulm and abdominal exam reveals no abnormalities. Diaper has meconium stool stained with large amount of blood. Labs reveal Hgb 16, Hct 47.2%, WBC 15000 with 60% neutrophile, 1% bands, 39% lymphocytes and 185,000 platelets. What is the most appropriate next step?
Order an Apt-Downey test!
-Given the marginal placental separation, the most likely source of bleeding is actually just ingested maternal blood. Hematemesis and melena are uncommon in the neonatal period, especially if gross bleeding has occurred at the time of delivery. The Apt-Downey test distinguishes between fetal and adult blood because fetal hemoglobin is alkali resistant and adult hgb isn’t. Adult hgb will convert to hematin on exposure to alkali, so if the Apt-Downey test proves that the blood was maternal in origin no further workup is required given the circumstances. Otherwise, we would need a more extensive workup.
A 1 yo is seen by the NP for a well child exam. The kid has had a URI for the past 2 days. Vitals are normal and growth parameters are at 50th percentile for age. His nose is slightly congested but notably he has new onset strabismus. What is the next best step in management?
Refer immediately to ophthamology!
-Strabismus would not be caused by URI but new onset strabismus should be sent to ophthamology to prevent abnormal binocular vision.
A 14 yo boy is seen in the ED from an avalanche caused by a barking chihuahua. When he was rescued his feet were whitish yellow and numb. He had no loss of consciousness or obvious injuries. T-96, P-90, RR-18. He is awake alert and oriented. Cardiopulm exam is normal and abdominal exam shows hepatomegally. His feet are coll blotchy in color and painful to touch. What is the most likely dx?
Frostbite!
-In frostbite the tissue is destroyed. Initial stinging is replaced by aching and culminates in numb areas. After rewarming the area becomes red blotchy and painful.
A 3 yo boy is seen by the pediatrician for a 3 week hx of vomiting. The family reports that he has had intermittent episodes of vomiting has become more irritable listless and is no anorectic. He feels warm. He has had no significant PMHx or developmental hx. Before this illness he was able to say 2-3 word sentences but is not only able to say single words. Parents deny and travel, sick contacts, and meds or drugs in the home. What is the most likely dx?
Tuberculous meningitis!
-This kid has had slow onset nonspecific neurologic difficulty, which rules out acute infections like HSV encephalitis or bacterial meningitis. Tuberculous meningitis is common b/w 6 mos and 4 years and the first stage lasts 1-2 weeks and produces nonspecific sx. The 2nd stage begins abruptly with seizures, lethargy, hypertonicity, hydrocephalus, and focal neurologic signs. 3rd stage includes coma, HTN, posturing, decompensation, and death.
An 8 month old infant is seen in the ED for diarrhea. The child has had a 2 day hx of nonbloody diarrhea and pooor fluid intake. P-180, RR-30, and BP-60/40. He has poor skin turgor, 5 second capillary refill, and cool extremities. What is the most appropriate fluid in managing his condition?
Normal saline!
-This kid is dehydrated and basically NS and LR are the best fluids for rapid bolusing. However, LR should not be used in the oliguric or anuric patient. Initial fluid bolus should be 20ml/kg.
