Pulm and GI Flashcards by Brianna Spahn

Typical vs atypical pneumonia

typical = acute onset, lobar consolidation on x-ray, involves pneumococcal spp

atypical = more indolent (> 24hrs) onset, lower peak temps, more prodromal sx like headache and sore throat, involves mycoplasma or chlamydia spp

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More likely to see what kind of pneumonia in school age children

Atypical

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More likely to see what kind of pneumonia in neonates

Group B Strep, Chlamydia

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More likely to see what kind of pneumonia in infants outside neonate period

Viral pneumonia

Serious bacteria pneumonia w staph aureus, strep pneumo

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Ill / toxic apearing child may be more likely to have what kind of pneumonia

Bacterial pneumo, or a complication of bacterial pneumo like empyema

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When considering pneumonia, what else should beo n the DDX

Atelectasis from foreign body or mucus plug

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A 2 year-old presents with the abrupt onset of cough, wheeze and tachypnea. He is afebrile. Physical exam reveals diminished air exchange and wheezing on the right.

What’s the DDx?

Foreign body aspiration
Asthma
Pneumonia
Bronchiolitis

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Tx for complete airway obstruction

back slaps and chest thrusts in head down position for infants, abdominal thrusts for older children

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Tx for partial airway obstruction

allow patient to cough, take to nearest emergency facility

Rigid bronchoscopy

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Male infant born at 38 weeks by scheduled repeat cesarean section prior to onset of labor.
Maternal history – good prenatal care, negative group B Strep cultures
Apgars 8/8
Within first hour of birth:
Tachypnea
Nasal flaring
Mild retractions

What’s the DDx?

Transient tachypnea of the newborn
Respiratory distress syndrome
Congenital diaphragmatic hernia
Meconium aspiration syndrome

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A 10 month-old presents with bouts of irritability during which he draws up his legs and appears to be in pain. He had a viral illness last week. His stools are heme test negative and he is very lethargic. There is abdominal distention and diffuse tenderness. What is your differential diagnosis?

Intussusception
Malrotation w/volvulus
Meningitis
Gastroenteritis

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A full-term 1-week-old boy presents with bilious vomiting and lethargy
Pertinent history: normal prenatal course, uncomplicated delivery, adequate weight gain since birth
Physical exam: fussy, pale, abdomen distended and tender to palpation, blood in diaper
Most likely diagnosis?

Malrotation w volvulus

Gonna need surgery

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An 8 year-old girl presents with abdominal pain, purpuric lesions on the buttocks and lower extremities, and knee and ankle pain. She reports her urine to be darker than usual.
Most likely diagnosis?

Henoch-Schonlein Purpura

Vasculitis:

*palpable purpura on lower extremities
- hematuria, bloody stools
*edema

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RLQ pain, abdominal guarding and rebound tenderness

Appendicitis

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Diarrhea – possibly bloody, fever, vomiting

Bacterial enterocolitis

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RUQ pain, may extend subscapular

Cholecystitis

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Purpuric lesions, joint pain, blood in urine, guaiac-positive stools

Henoch-Schonlein Purpura

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RUQ pain, jaundice

Hepatitis

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Inguinal mass, lower abdominal or groin pain, emesis

Incarcerated inguinal hernia

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Colicky abdominal pain, currant jelly stools

Intussusception

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Abdominal distention, bilious vomiting, blood per rectum, usually presents in infancy

Malrotation with volvulus

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Hematuria, colicky abdominal pain

Nephrolithiasis

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(Severe) epigastric, abdominal pain, fever, and persistent vomiting

Pancreatitis

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Emesis, history of prior abdominal surgery

Small bowel obstruction

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Fever, sore throat, headache, +/- abdominal pain

Streptococcal pharyngitis

Fever, vomiting, and diarrhea in infants; back pain in older children

UTI

Irritability, pallor, bloody diarrhea, anemia, thrombocytopenia

Hemolytic-uremic syndrome

Weight loss, diarrhea, malaise

Inflammatory bowel disease

CXR appearance of RDS

"Ground glass" - fine reticular granularity Initial CXR may be normal, w progression over 6-12hrs

Most common lower respiratory tract infection in infants and children <2yo

Bronchiolitis

Most common causative agent of bronchiolitis

RSV Adenovirus, parainfluenza, influenza

Bronchiolitis - diagnosis studies?

Clinical diagnosis - labs and imaging not recommended

Recent URI, copious rhinorrhea Cough, tachypnea, tachycardia Nasal flaring, grunting

Bronchiolitis / RSV

Earliest, most sensitive sign for bronchiolitis / RSV

Tachypnea

Bronchiolitis / RSV management

Hydration!!! Oxygenation Nasal suction *Ribavarin only for severe cases*

Leading cause of infant death from viral infection

RSV

Most common complication of RSV

Otitis media

Recurrent Wheezing vs Chronic Asthma

Recurrent wheezing more in early childhood, triggered by viral URI's Chronic asthma is associated w allergy and persists into later childhood / adulthood

Intermittent dry coughing and expiratory wheezing SOB and chest tightness in older children Symptoms worse at night

Asthma

Expiratory wheezing, prolonged expiratory phase

Asthma

Acute inflammatory upper airway obstruction, ddx

``` Croup Epiglottitis Aspiration of foreign body Retropharyngeal or pertonsillar abscess Extrinsic compression of the airway (laryngeal web, vascular ring ```

URI sx for 1-3 days | Barky cough, hoarseness, inspiratory stridor

Croup

Age group most common for Croup

3 month - 5 years, peaks at 2 yrs

Most common etiology and long medical name for Croup

Parainfluenza virus Laryngotracheobronchitis

CXR indicating Croup

"Steeple sign" - upper trachea appears closed, gradually opens as it descends

Croup management at home

Airway management, usually done at home - cool mist - steamy bathroom

Croup management in ED

Nebulized racemic epinephrine | Corticosteroids

When to hospitalize for croup?

``` Severe stridor at rest Respiratory distress Hypoxia Cyanosis Depressed mental status ```

Acute, fulminating course of high fever, sore throat, dyspnea, rapidly progressing respiratory obstruction

Acute Epiglottitis

Epidemiology of epiglottitis

In the past was largely due to Haemophilus influenzae type b now usually due to Streptococcus pyogenes, Streptococcus pneumoniae, and Staphylococcus aureus

Otherwise healthy child suddenly develops a sore throat and fever Within few hours – toxic appearing, difficulty swallowing and breathing Drooling

Acute Epiglottitis

Diagnosis of epiglottitis

Visualization of a large, “cherry-red” swollen epiglottitis Should only be performed by someone capable of maintaining airway – i.e. ENT or anesthesiologist

CXR of acute epiglottitis

"thumb sign"

Epiglottitis management

Airway establishment - intubation O2 Blood Culture Antibiotics - ceftriaxone, cefixime

Etiology and course of whooping cough / pertussis

6 week course | Bordatella pertussis

Evolves into inexorable paroxysms – hallmark of the disease | Number and intensity of paroxysms progresses over days to a week and then plateaus for days to weeks

Whooping cough / pertussis **reportable disease**

Suspect in patient who has predominant complaint of cough especially in the absence of fever, malaise, myalgia, exanthema or sore throat

Whooping cough / pertussis **reportable disease**

Pertussis tx

Erythromycin or azythromycin Hospitalize infants under 3 months

Pertussis complications

``` Pneumonia Seizures Apnea Secondary infection Mortality 1% in < 2month olds ```

Non-bilious emesis that becomes progressively forceful Dehydration, weight loss Birth- 3 months

Pyloric stenosis

First line testing for pyloric stenosis

Ultrasound | Look for thickening of pyloric valve, elongation of channel

Metabolic panel in pyloric stenosis will show

hypochloremic metabolic alkalosis due to loss of hydrogen ions and chloride from emesis

Most common cause of intestinal obstruction in children aged 3 months to 6 years of age

Intussusception 60% occur before first birthday 80% occur before second birthday Uncommon < 3 months, > 6 years

Intussusception usually occurs at what part of bowel

ileocecal junction

Pathophys of intussusception

Obstructs venous return ➔ engorgement of intussusceptum ➔ edema, bleeding from the mucosa ➔ bloody stool (CURRANT JELLY STOOL)

Intussusception Tx

Hydrostatic/ pneumatic reduction – with barium or water soluble contrast Successful 80-95% of the time Recurrence: 10% Surgical reduction Manual reduction of intussusceptum Resection for ischemia

True diverticulum, containing all bowel layers (mucosa, submucosa and muscularis propria), in small intestine Most common congenital GI abnormality

Meckel's diverticulum

Most common times constipation presents

Infancy: at transition to solid foods Toddler: at transition to toilet training School-age: at entry to school

“Voluntary or involuntary passage of feces into inappropriate places at least once a month for 3 consecutive months once a chronologic or developmental age of 4 has been reached”

Encoparesis 4% in 5 – 6 year olds 1.5% in 11 – 12 year olds M:F = 4-5:1