Peds Uworld

Question 1

Metatarsus Adductus vs Clubfoot

Answer 1

MA- Medial deviation of the forefoot that moves laterally with passive and active movement
Clubfoot- Medial and upward deviation of the fore and hind foot. Tx- serial manupuliation and casting as soon as born. Consider karyotyping b/c associated with chromosomal abnormalities.

Question 2

Preseptal (perirbital) vs postseptal (orbital)

Answer 2

Periorbital- Eyelid edema, erythema, tenderness, leukocytosis, fever

Orbital- above PLUS opthalmoplegia, pain with movement, proptosis and vision impairment. Tx iwth IV AB b/c risk of blindness, abcess of the brain, venous sinus thrombosis

Question 3

Pediatric Viral Myocarditis

Presentation, causes, tx

Answer 3

Presentation- viral prodrome then heart failure *dyspnea, syncope, tachy, N/V, hepatomegaly

Dx- x-ray, echo, ekg, Gold STANDARD- biopsy to show infiltrate of myocardium with myocyte necrosis

Bugs- adeno and coxsackie

PE- can have large liver and holosytolic murmur from dilated cardiomyopathy

Question 4

Vesicoureteral reflux

Answer 4

Presentation- 2-24 months with UTI
Dx- first get renal US afer 1st UTI. IF they have recurrent UTIs get a voiding cystourethragram

VCUG
Grade 1- into a non dilated ureter
Grade 2- into pelvis and calyxes without dilation
Grade 3- mild to moderate dilation of ureter, pelvis and calyces with minimal blunting
Grade 4- moderate urethral touristy and dilation of pelvis
Grade V- Gross dilation of the ureter, pelvis and calyxes and loss pf papillary impressions and urethral tortousity

Question 5

Spondylooslisthesis

Answer 5

Developmental disorder characterized by a forward slip of the vertebrae (L5/s1). Presents with progressive back pain and neurological symptoms.

Vs primary/metastasis to spine- usually doesn’t have step off

Question 6

Primary Amenorrhea

Answer 6

If no menses by 14 start work up

Pelvis US
Uterus–> FHS
FSH low get MRI, FSH high karotype

No uterus–> karotype
46XX abnormal mullerian
46XY- androgen insensitive

Question 7

Tension Pneumothorax

Answer 7

Triad of Sudden hypoxia, trachea deviation, and unilateral absent breath sounds
Tx- needle thoracostomy

Question 8

Niacin defeciecny

Answer 8

Pellagra- diarrhea, dermatitis (sun exposed areas), and dementia. and glossitis

Patient either in a 3rd world country with corn and starch as main diet or bowel absorption

Question 9

Prepubertal bleeding

Answer 9

Trauma- unintentional fall, sexual abuse
Rhabdomyosarcoma- rare, kids over 3, protruding vaginal nodules
Estrogen withdrawal- neonatal period, <1 week and exam otherwise normal

Question 10

fanconi

Answer 10

Apastic anemia and progressive bone marrow failure. Autosomal recessive

Appearance- kids <16 short stature, microcephaly, abnormal thumbs, hypogonadism, hypo/perpigmented area, cafe au lait spots, eye and ear abnormalites

Cause- chromosomal break

Question 11

Nec

Answer 11

Presentation- premature, small, heart disease (decreases profusion to the gut)

Clinical- vital sign instability, GI signs- vomitting, lood in stool, abdominal tenderness/distension

Xray- pneumotosis intestinalsis, portal venous gas

Tx- NPO, borad spectrum AB, possible sx

Question 12

Levels of dehydration

Answer 12

Mild- 3-5% volume loss no clinical signs
MOderate 6-9%- decreased skin tugor, dry mucus membranes, tachy, irribility, decreased UOP
Severe >10% cool, clammy skin, dry mucous membranes, sunken eyes, sunken fontanelle, tachy, lethargy, NO UOP

Question 13

Vit K in neonates

Answer 13

Give two paraenteral injection of Vitamin K becauase it has poor placental transfer, absent gut flora, and immature liver so they cant produce their own.

Signs may be bruising, bloody stool, IC hemorrhage, and elevated PT with normal or elevated PTT

Question 14

Presentation, Labs and Diagnostics of Hereditary Spherocytosis

Answer 14

Increase indirect bili, splenomegaly, jaundice, hemolytic anemia

Labs- increase bili, Increase RDW, increase MHCH

Dx- esosin 5 maleimide binding test, osmotic fragility test

Tx- splenectomy

Question 15

Risk factors for RDS in neonates

Answer 15

Premature
Maternal DM
C section with no labor
Male sex
perinatal asphyxia

Question 16

Presentation of SSTrait

Answer 16

HbA 50% and HbS- 35% Hb F<2%

increased risk of renal issures and usually have painless hematuria that results from sickling in the medulla. Isosthernuria (impairment in concentration) is also common and they have nocturia and polyuria.

Question 17

Lymphadenitits in children

Answer 17

Presentation kids under 5 nontoxic appearing and the affected node is warm, tender, erythematous and 3-6cm in size— acute and unilateral is usually bactieral (staph Aureus or strep)

Question 18

Iron poisoning
Presentation
Diagnostic
Tx

Answer 18

Abdominal pain, N/V, hypotensive shock, metabolic acidosis. Within 2 days hepatic necrosis, within 6 days pyloric stenosis

Diagnostic- anion gap metabolic acidosis and radioopaque pills

tx- bowel irrigation, deferoxamine, supportive care

Question 19

RTA Type 1, 2, 4

Primary defect, urine pH, serum K, and causes

Answer 19

RTA 1- distal, poor hydrogen secretion into urine, pH> 5.5, serum K- low-normal, causes- genetic, medicaiton, AI

RTA 2(proximal) - poor bicarb resorption, pH urine<5,5 (urine is acidified by alpha- intercalated cells in the Collecting ducts ), serum K- low/normal, fanconi syndrome

RTA 4- aldosterone resistance, urine ph <5.5, serum K high, Causes obstructive uropathy and congential adrenal hyperplasia

All RTAs present with failure to thrive due to poor cellular growth and divisin in acidici conditions

Question 20

Clinical features and management of caustic ingestion in kid

Answer 20

Features- laryngeal damage- hoarseness and stridor, esophageal damage, hysphagia gastric damage- bleeding, epigastric pain

Management- ABC, decontamination so remove clothing and DO ENDOSCOPY within 24 hours

Avoid anything that could induce vomitting like milk, water, activated charcoal, vinegar, NG lavage as this could icnrease injury. BG should be placed with endoscopy as to not damage or perforate.

Question 21

Benign vs pathologic murmur in kids

Answer 21

Benign- kid otherwise asymptomatic, usually a mid systolic murmur taht DECREASES WHEN STANDING AND WITH VALSALVA. Don’t work up

Pathologic- chest pain, diaphoresiss, syncope, heart defect, fam hx

Harsh, holosytolic increases with standing and valsalve.
Get EKG and Echo and refer to cardio

Question 22

Most common organisms for osteo in <2months, 2months-4, >4, SSD

Answer 22

<2 months- E coli and group B
2months-4yrs- Kingella kingae
>4 yo- Staph Aureus
SSD- salmonella (3/4 of all SSD osteo), S aureus– remember that microinfarcts can impair flow and increase risk of osteo. Tx empiraically with ceftriaxone and anti-staph dxs (oxacillin, vanc)

Question 23

OSteoid OSteom
CP
TX
DX

Answer 23

Benign bone-forming tumor common in adolesecents
CP- focal tenderness, deformities, or swelling but usually no findings in adolescents. Pains worst at night and better with NSAIDS
X-ray- hypodense lesion on x-ray
TX- NSAIDs for pain, serial examination and x-rays for 4-5 months to monitor

Question 24

Reyes- 
Etiology
CP
Lab
Dx
Tx

Answer 24

Etiology- ASA in kids in the setting of viral infection (Flu or varicella usually)
CP- Acute liver failure and encephalopathy
Lab- elevated liver enzymes, increase PT/PTT, increase NH3
Dx- liver biopsy showing MICROvesicular steatosis
Tx- Supoprtive

Question 25

HUS- pathogenesis CP Labs Tx

Answer 25

Shiga toxin from Ecoli causing vascular damage and microthrombi form CP- FATRN- fever, prodrome of bloody diarrhea, bruising and petechia, edema/oliguria Labs- low platelets, anemia, AKI- Increased BUN and Cr Tx- dialysis, fluids, electrolyte correction

Question 26

Workup for bilious vomitting in a newborn

Answer 26

1. X-ray to make sure there isn't pneumoperitoneum requiring immediate sx 2. Water soluble contrast enema- if there is microcolon we would consider meconium ileum and hope the hyperosmolar enema breaks up the meconium. 3. If the contrast enema shows a transition zone then consider rectal biopsy for hirschsprung

Question 27

common resp tract infection in children Tx for who Complications

Answer 27

Bronchiolities caused RSV <2 years old= most common Clinical presentation- wheezing, crackles, resp distress... can have nasal congestion and cough tx- supportive Palivizumab for premature <29 weeks, chronic lung develop prematurity, hemodynaically significant heart disease Complications- apnea and resp failure

Question 28

Presentation of trachoma/bug/tx

Answer 28

Child in unsanitary conditions presenting with conjunctival injection, tarsal inflammation and pale follices. Kids can often concomitant nasopharyngeal infection. Due to Chlamydia serotypes A, B, and C Complications- repeated infection can lead to scarring and inversion (trichiasis) and blindness. Dx- can be clinical- TARSAL CONJUNCTIVAE or use giemsa stain. Tx- azithromycin or eyelid sx.

Question 29

Risk factors for UTI in kids and when to do a workup

Answer 29

Risk factors- girls, uncircumcised penis, underlying renal anomaly Any kids with a fever >102.2 should have a occult UTI investigation. If they kid is in diapers straight cath, ua, and culture. If they aren't they UA and culture

Question 30

``` Anemia of Prematurity Etiology Clinical P Labs Tx ```

Answer 30

Etiology- low EPO, short RBC life span, iatrogenic blood sampling Clinical manifestations- usually asymptoamtic, tacycardic, apnea,, poor weight gain Lab findings-low Hb and low hemotocrit, low RC, normocytic, normochromic RBCs Tx- iron, minimize blood draws, minmize transfusion

Question 31

igA CP Dx Tx

Answer 31

``` CP- can be asymptomatic, asthma/eczema AI Anaphylaxis to igA containing blood Recurrent sinopulmonary and GI infections, ``` Dx- Low or absent igA with normal IgG, IgM Tx- supportive, medical alert bracalet for transfusions

Question 32

Tx of croup

Answer 32

Mild (no stridor at rest)- steroids Moderate/severe- stridor at rest- steroids and nebulized epinephrine If they fail this then intubate

Question 33

Biliary Atresia CP Dx Tx

Answer 33

CP- pale stool, direct >2 o2 20% of the total bili. Hepatomegaly, mild elevated transaminases Dx- Liver US (is there a gallbladder) Hepatobiliary scintigraphy (does the liver excrete the tracer to the small bowel) LIver biopsy Intraopertive cholangiogram (Gold standard) Tx- Hepatoportoenterostomy or liver transplant

Question 34

Osgood-Schlatter

Answer 34

Common knee pain in adolescent male. During rapid periods of growth in which the quads tendon puts traction on the apophysis of the tibial tubercle where the patellar tendon inserts. Worst during sports. PE- tenderness and edema over the tibial tubercle.

Question 35

Retropharyngeal abcess vs. epiglottis

Answer 35

BOth- fever, dysphagia, muffled voice, drooling RPA- inability to extend neck and widened preveretebral space. Get a CT with contraast

Question 36

Work up for precocious puberty

Answer 36

Secondary sexual development girls <8 and guys <9 1. Check bone age 2. Advance- basal LH - Low- GNrh independent precocious puberty - High- GnRH (central) dependent 2. Normal

Question 37

Acute Cervical Adenitis Bugs for Bi/UNilateral Bugs CP

Answer 37

CP- kids under 5, enlarged, markedly tender, warm and erythematous. Clinical dx and treat with AB Unilateral- staph and strep Bilateral- Adenovirus and EBV/CMV

Question 38

Presentation of Herpangina | Bug

Answer 38

Coxsackie A Early fall/summer Fever, phayngitis, gray vesicles ulcers on the POSTERIOR oropharynx Can also have rashes on hands and foot vs Strep (positive for TENDER adenopathy and exudate)

Question 39

Contraindications to rotavirus

Answer 39

1. Anaphylaxis to vaccine ingredients 2. Hx of intussuception 3. Hx of uncorrected congenital malformations of the GI tract 4. Severe combined immuno disease

Question 40

Neonatal Conjunctivitis

Answer 40

Chemical <24 hours- mild conjunctival irritation and tearing after silver nitrate. Tx with lubricational Gonococcal 2-5 days. Marked eye swelling, profuse prulent discharge and corneal edema/ulceration- Tx. sigle IM dose of 3rd gen cephalosporin Chlamydial 5-14days. Mild eyelid swelling, watery, seroanguinous or mucoprulent eye discharge- Tx PO macrolide

Question 41

Impetigo

Answer 41

Non-bullous- staph or group A strep, painful non-pruitic pustules, honey contrusted Bullous- staph, rapidly enlarging flaccid bullae with yellow fluid. Tx- Limited skin involvement topical AB- mupriocin Extensive skin involvement- oral AB- cephalexin, dicoxacillin, clinda

Question 42

MCune Albirght

Answer 42

3 ps Precocious puberty, Pigementation- cafe au lait spots Poloyostotic firbous dyaplasia - bone defects. G-protein cAMP kinase functions

Question 43

Eczema/atopic dermatitis

Answer 43

Etiology- dysfucntion in synthesis of stratum corneum Infant- itchy, red, scaly, crusted on extensors Tx- topical emolients and possible steroids Complciations- cellulitis, eczema herpeticum and discomfort interrupting sleep

Question 44

Laryngomalacia

Answer 44

Pathophys- increased laxity of the supraglottic structures CP-stridor and "weird breathing" that peaks at 4-8 months. Worst when feeding and supine. Dx- clinically but confirmed on flexible laryngoscopy Management- reassurance for most, supraglottoplasty for severe Usually self resolve by 18 months

Question 45

Vascular rings

Answer 45

Biphasic stridor and feeding difficulties 2/2 compression of teh trachea and esophagus. Dx- Barium swallow and MRI with angio

Question 46

X-linked agammaglobulenemia

Answer 46

CP- recurrent sinopulmonary and GI infections (pneumo Giardia) AFTER 6 MONTHS OF AGE , Absence of lymphoid tissue (scant LN, tonsils) Dx- Low B cells, and normal T cells, no response to vaccines Tx- Immunoglobulin replacement therapy and prophylactic antibiotcs

Question 47

Iron Poisoning

Answer 47

CP- N/V, abdominal pain, hypotensive shock, metabolic acidosis with anion gap, 30mins to 4 days, radio-opaque pills. Iron can be corrosive to the GI tract, gastric scarring and hematemesis vs acetoaminophen that takes usually like 24 hours 2 days- hepatic necrosis 2-8 weeks- pyloric stenosis Tx- whole bowel irrigation, deferoxamine, supportive care

Question 48

Aplastic Crisis

Answer 48

SSD- chronically low anemia, high retic count aplastic crisis- acute drop in Hb, without compensatory rise in RC and WITHOUT spelnomegaly

Question 49

Coartaction of the aorita

Answer 49

Pathology- thickening of tunica media of aortic arch near ductus arteriosus CP- HTN in upper extremity, weak femoral pulse, low post ductal oxygen saturation Heart failure (irritability/poor feeding/diaphoresis) Tx- surgical repair

Question 50

Leukocyte Adhesion Defeciency

Answer 50

LAD Lots of infections skin and mucosal infections Absent pus formation Delayed Umbilical Cord seperation MARKED PERIPHERAL LEUKOCYTOSIS WITH NEUTROPHILIA- neutrophils can't go to the site of infection because of defect in LFA-1 (CD-18) gene inhibiting adhesion and migration

Question 51

TET | Murmur type

Answer 51

Harsh sytolic Murmur ejection murmur over left upper ejection murmur. Single S2 becuase pulmonic is inaudible

Question 52

Breastfeeding vs Breast Milk Juandice | vs Biliary Atresia

Answer 52

Breastfeeding failure jaundice- first week of life. High UNCONJUGATED bili Lactation failure resulting in decreased bilirubin elimination, increase enteroheptic circulatin and suboptimal breastfeeding with signs of dehydration Breast Milk Jaundice starts at age 3-5 peaks at 2 weeks, high levels of B-glucoronidase in breast milk decojugate inttestinal bilirubin and increase enterohepatic ciruclation Biliary atresia- high CONJUGATED bili

Question 53

Legg Calve Presentation

Answer 53

Progressive Antalgic gait, unilateral subacute hip pain in a male, thigh muscle atrophy, decreased ROM, collpase of ipislateral femoral headon plain pelvic x-ray .

Question 54

Tx of DiGeorge

Answer 54

thymic transplant Should have dysmorphic facial features, paltal defects, cardiac deformatives

Question 55

tx of WAS

Answer 55

Hematopoietic stem cell transplant b/c of the x-linked impaired cytoskelton

Question 56

Absence Seizures

Answer 56

Occurence during all activities Length <20 seconds Lack of response to verbal or tactiles stimulation Presence of automatism ((eyelid fluttering) Provoked by hyperventilation and dignosed by 3Hz psike waves on ECG

Question 57

Spondylolisthesis

Answer 57

Developmental disorder (usually presents in preadolescents) characterized by a forward slip of vertebrae L5 or S1. Can cause chronic back pain and neurologic problems. Palapble STEP OFF on exam.

Question 58

INsulin in refeeding

Answer 58

carbs trigger insulin release and that causes an uptake of K+, phos, and mag. The decrease

Question 59

Mumur in 1, Ebstein 2. PDA

Answer 59

1. triple or quadruple gallp widely slspilt S1 and S2 sounds plus loud S3 and/or S4 and holosytolic murmur at LLSB 2. Machine like associated with rubella 3. TOF- cres-decres systolic murmur heard best at and single second heart sign

Question 60

Workup for abnormal uterine bleeding

Answer 60

CBC, coag studies, pregnancy test In peds like immature axis- treat with high dose oral estrogen/progestin contraceptive pills. stabilizes the endometrium and stops menstrual bleeding

Question 61

Indications for renal and bladder US

Answer 61

Infants and children <24 months with first febrile UTI Recurrent febrile UTIs in children of any age Non response to AB UTI in child of any age with family hx or renal or urologica disease or personal hx HTN or poor growth

Question 62

Indications of Cystourthrogram

Answer 62

Less than <1 month and children <2 yo with recurrent UTI, or first UTI with an organism other than Ecoli. Or abnormalities on US

Question 63

Choanal Atresia

Answer 63

Aggravated by feeding, relieved by crying. dx- failure to pass catheter and confirmed on CT ``` CHARGE Coloboma Heart Defects Atresia chonae Retardation of growth/development GU abnormalities Ear abnormalties ```

Question 64

Retropharygneal Abcess

Answer 64

Dyspagia, drooling, muffled voice, neck stiffness, trismus likely in the setting of pre existing URI in a kid 6 months to 6 years old PE- inability to extend neck and widened pre-vertebral space (vs epiglottitis which shows thumb sign)

Question 65

CGD

Answer 65

X-linked disorder that prevents phagocytic oxidative burst (formation of H2O2) and therefore impairs intracellular killing by phagocytes Recurrent infections from catalase positive organisms in the lnungs and soft tissue. Dx is neutrophil function testing- dihydrohodamine 123 test and nitroblue tetrazolium test

Question 66

Test for different immunodef 1. CGD 2. X-linked Brutons 3. Complement defeciecny 4. DiGeorge

Answer 66

1. Neutrophil levels- dihydrodamine 123/nitroblue tetrazolium test 2. B cell and immunoglobulin levels 3. CH50 4. T cell

Question 67

Seborrheic dermatitis

Answer 67

Peaks in infancy Erythematous plaques and thick/yellow/greasy sclares Located on scalp and face face Tx- emolients 2nd line- topical antifungals and low potency steroids.

Question 68

Biliary Atresia Presentation Pathophys Dx Tx

Answer 68

Presentation- normal at first then week 2-8 juandice and elevated conjugated bili. Light colored stool and dark stool, mild elevation in transaminases Pathophys- progressive obilteration of the extrahepatic biliary ducts so no connection the liver to small bowel. Without tx will cause inflamed liver (hepatomegaly and hepatitis) Dx- US- no or abnormal GB Hepatobiliary scinitigraphy- failure of tracer excretion Liver biospy- expanded portal tracts with portal tract edema GS- intraoperative chlangiogram- biliary obstruction Tx- liver transplant (number one reason for pediatric liver trasnplant)

Question 69

Croup treatment-

Answer 69

No stridor then steroids and himidifed air Moderate/severe stridor- steroids and nebulized epi Pending resp failure- intubate

Question 70

Murmur in each cardiac problem

Answer 70

Transposition of the great vessels- Single S2 could have no murmur (POF) or VSD/PDA murmur- egg on a a string TOF- left upper border single S2, cres/des systolic murmur + VSD murmur Tricuspid Ateriosus- single S2 TAPVRWO = severe cyanosis, resp distress- pulm edema and snowman sign

Question 71

Resp failure in asthamatics

Answer 71

``` Minimal to no wheezing Cyanosis Chest wall retrations Altered mental status Extreme fatigue ``` Lab findings low PO2 High PCO2 Low pH- resp acidosis

Question 72

varicella immunity

Answer 72

Children are not considered immune unti lthey have two doses (1 and 4) or they've been infected. If not immune and exposed >1 yo, exposed int he last 5 daysand immunocompetetn given them a varicelle vaccine If pregnant or immunoincompetent give then varicella immunogolbulin Under <1 don't need anything

Question 73

Pathological Juandice

Answer 73

- Day one elevated- do coombs b/c likely hemolytic - Over 12 at any time - Direct is >2- always consider sepsis Bonus- fast rate of rise

Question 74

X-ray findings 1. TTN 3. RDS 3. Peristant Pulm HTN

Answer 74

1. TTN- peri-hilar streaking/air trapping due to retained fluid 2. White out- diffuse reticulogranular appearance, air bronchograms 3. Clear lungs with decreased pulmonary vascularity