VLC Peds 2: Young Child (up to 4y) Flashcards
(113 cards)
1
Q
When examining an infant, what components do you perform first and why?
A
Ausculatation of heart and lungs: in case infant starts to cry (wouldn’t be able to auscultate well then)
2
Q
What is the DDx for diagnosis of limp / refusal to walk in a child?
A
Leukemia
Reactive arthritis
Septic arthritis
Juvenile idiopathic arthritis
Transient synovitis
Slipped capital femoral epiphysis (SCFE)
Trauma
Osteomyelitis
Legg-Calve-Perthes disease
3
Q
What must always be considered on the DDx for a child refusing to walk?
A
Leukemia
4
Q
How might leukemia present, before systemic signs like fever and weight loss?
A
Bone pain
Can present as limp or refusal to walk, or localized discomfort of jaw, long bones, vertebrae, hip, scapula, or ribs.
5
Q
What causes bone pain in leukemia?
A
Replacement of bone marrow by leukemic cells
6
Q
What is osteomyelitis?
A
Infection of the bone
Usually bacterial, most often Staph aureus (and before immunization, Haemophilus influenzae)
7
Q
What proportion of osteomyelitis cases involve a history of fever?
A
About half
8
Q
How does leg or hip osteomyelitis present in toddlers ?
A
Pain and refusal to bear weight
9
Q
Is the presentation of osteomyelitis rapid or indolent?
A
Indolent: can take 5-10 to diagnose
10
Q
Reactive arthritis is most common in which age group?
A
Adolescents and young adults
11
Q
True or false: children with reactive arthritis usually have fever
A
False: usually afebrile
12
Q
What typically precedes reactive arthritis?
A
Infection outside the joint, eg GI or GU, usually 2-4 weeks previously
13
Q
What is classically associated with reactive arthritis?
A
Urethritis and conjunctivitis
Note: this presentation is uncommon in children
14
Q
What is septic arthritis?
A
Bacterial infection of a single joint, usually in a lower extremity
15
Q
Septic arthritis is most common in which age group?
A
0-6 years old
16
Q
What non-joint symptoms present with septic arthritis?
A
High fever Constitutional Sx (decreased appetite, irritability, malaise)
17
Q
What is transient synovitis?
A
Transient inflammation of a joint. Relatively common.
Etiology not clear; some suspect post-infectious
18
Q
What non-joint symptoms present with transient synovitis?
A
Few: there may be a low-grade fever, but no significant constitutional Sx otherwise.
19
Q
What is the time course of transient synovitis?
A
Acute onset (eg one day)
Pain usually completely resolves within 3-10 days
20
Q
What is juvenile idiopathic arthritis?
A
Group of disorders characterized by chronic inflammation of joints
Criteria:
- children must be less than 16 years of age
- must have arthritis in at least one joint for more than six weeks
21
Q
What are the subtypes of juvenile idiopathic arthritis?
A
Systemic Oligoarthritis Polyarthritis Psoriatic arthritis Enthesitis-related arthritis Other
22
Q
What features does systemic JIA have?
A
Systemic: constitutional Sx and rash
23
Q
What features does oligoarthritic JIA have?
A
Onset is acute
Usually affects the knee
Associated with asymptomatic iridocyclitis (infl of iris and ciliary muscles)
24
Q
What is the most common hip disorder in adolescents?
A
Slipped capital femoral epiphysis
25
What is slipped capital femoral epiphysis?
Posterior displacement of capital femoral epiphysis relative to the femoral neck at the cartilage growth plate
(actually is anterior/anterolateral displacement of femoral neck--head & epiphysis are well held in acetabulum)
26
What are the symptoms of slipped capital femoral epiphysis?
Limp and impaired internal rotation
27
How is slipped capital femoral epiphysis managed?
Depends on degree of slip, & complications (AVN of femoral head, destruction of articular cartilage)
Usually involves pinning to stabilize epiphysis
28
What is Legg-Calve-Perthes disease?
Indolent condition of unclear etiology
Involves avascular necrosis of capital femoral epiphysis
29
What is the management and prognosis of Legg-Calve-Perthes disease?
Prognosis: usually self-resolving, may lead to complications like femoral head deformity & degenerative arthritis
Treatment usually involves referral to Ortho, but is usually conservative
30
In which demographic group is Legg-Calve-Perthes disease most common?
Boys 4-10 years old
31
In which areas are bruises not suspicious in young active children? In which area are bruises suspicious?
Not suspicious: Bony prominences (eg shins, forearms)
Suspicious: well-cushioned areas (e.g. buttocks, back)
32
True or false: bruises cannot be reliably aged based on colour
TRUE
| Don't ever say "bruises in various stages of healing" -- you don't know! Can describe colour instead
33
What does the Ortolani maneuver test?
Dislocated hip, specifically whether you can reduce an existing dislocated hip
Move: Ortolani Opens
34
What does the Barlow maneuver test?
Dislocated hip, specifically whether it is very easy to posteriorly dislocate a hip
Move: Barlow pushes Back
35
What is the spectrum of developmental hip dysplasia?
```
hips that are
dysplastic
dislocatable
subluxated (partially dislocated)
dislocated
```
36
Name 3 risk factors for developmental hip dysplasia
Female sex
Breech delivery
Family history of DDH
37
What are the two most common manifestations of Lyme disease?
Rash
Arthritis
Arthritis is the most common manifestation of late Lyme disease
38
How is Lyme arthritis diagnosed?
Clinically, based on rash and other symptoms
39
What other symptoms are associated with Lyme arthritis?
```
Characteristic rash (erythema migrans)
Fever
Malaise
Fatigue
Headache
```
40
What joints are most commonly affected by Lyme arthritis?
Large joints closest to the rash
41
True or false: Lyme arthritis occurs only once
False: it can occur only once, but it may also relapse
42
What symptoms and investigations are used to predict septic arthritis of the hip (for further Ix and definite Dx)?
```
Non-weight-bearing
Fever
Elevated WBC
Elevated ESR
Elevated CRP
```
43
How is septic arthritis diagnosed?
Joint aspiration
Should be performed by ortho
Aspirate then sent for culture
44
What are the most common causative organisms of septic arthritis?
Staphylococcus aureus
Streptococcus (neonate: group B; infant and older child: Group A and Streptococcus pneumoniae)
Haemophilus influenzae type b (in unimmunized children)
Neisseria gonorrhea (adolescents)
Kingella kingae (in children less than 4 years)
45
What is the management of septic arthritis?
- Abx (empiric first, targeted after culture)
- May require I&D
May require prolonged Abx and repeat aspiration / I&D
46
What is the treatment of transient synovitis?
Rest and ibuprofen
47
What is the prognosis of transient synovitis?
Good: small chance of recurrence, but no long-term effects.
Does not predispose individuals to arthritis.
48
What is important to ask about on history for a child with a limp?
- Bruising
- Any previous similar episodes
- Recent sickness
- Other Sx (eg constitutional)
- Sick contacts / exposures
49
What labs are most useful to order in initial evaluation of painful hip?
WBC (CBC)
CRP
ESR
50
What is the AEIOU-TIPS mnemonic for altered mental status?
AEIOU-TIPS
```
Alcohol, ingested toxins
Epilepsy, encephalitis, endocrine, electrolytes
Infection (meningitis/sepsis)
Overdose, opiates, oxygen deprived
Uremia (renal failure)
Trauma, temperature
Insulin
Psychosis
Stroke, shock, space occupying lesions
```
51
Give a DDx for a 2yo with altered mental status
Infection (sepsis, meningitis, encephalitis)
toxic ingestion
trauma
seizure
52
What are the first five steps in management of a child presenting with acute altered mental status?
ABC
Vitals
Glucose
53
What history should be gathered urgently when a young child presents with AMS?
Fever
Events
Possible toxic exposures
54
How do you initially stabilize a child with hypoglycemia?
A bolus of 10% or 25% solution of dextrose (D10 or D25)
55
How do you initially stabilize a child with tachycardia and hypotension?
A bolus of 20 cc/kg normal saline
56
What are the 5 main toxidromes?
```
Cholinergic
Anticholinergic
Sedative-hypnotic
Opioid
Sympathomimetic
```
57
Name 5 features of the cholinergic toxidrome (7 listed)
Miosis and blurred vision
Increased gastric motility (nausea, vomiting, diarrhea)
Excessive tearing, salivation, sweating and urination
Bronchorrhea and bronchospasm
Muscle twitching and weakness
Bradycardia
Seizures and coma
58
Name 5 features of the anticholinergic toxidrome (9 listed)
Mydriasis (dilated pupils)
Dry skin
Red skin (flushed)
Fever
Delirium and seizures
Tachycardia
Urinary retention
Ileus
Blind as a bat, dry as a bone, hot as a hare, red as a beet, mad as a hatter
59
Name 5 features of the sedative-hypnotic toxidrome (5 listed)
Blurred vision (miosis or mydriasis)
Hypotension
Apnea and bradycardia
Hypothermia
Sedation, confusion, delirium, coma
60
Name 5 features of the opioid toxidrome (5 listed)
Miosis (constricted pupils)
Respiratory depression
Bradycardia and hypotension
Hypothermia
Depressed mental status (sedation, confusion, coma)
61
Name 4 features of the opioid toxidrome (4 listed)
Mydriasis
Fever and diaphoresis
Tachycardia
Agitation and seizures
62
Diphenhydramine & tricyclic antidepressants cause which toxidrome?
Anticholinergic
63
Cocaine, amphetamines, and pseudoephedrine cause which toxidrome?
Sympathomimetic
64
Neostigmine, ipratropium, rivastigmine, donepizil cause what toxidrome?
Cholinergic
65
Organophosphate insecticides cause which toxidrome?
Cholinergic
66
What labs should be ordered for a child with suspected toxic ingestion?
```
Glucose
Lytes and/or blood gas
EKG
Tox screen
Acetaminophen
```
67
Why do acetaminophen on top of the standard tox screen?
- not included on standard
- most common accidental ingestion
- common co-ingestion
- management is guided by plasma concentration, so separate serum level is recommended
68
What clinical characteristics would contraindicate use of activated charcoal?
Loss of ability to protect airway (due to risk of aspiration)
69
Until what age should corrected gestational age be used?
2 years
70
How is corrected gestational age calculated?
40 - weeks at birth
Subtract that from current age
Eg 18mo born at 29w:
40-29 = 11
18mo - 11w = ~15.5 mo
71
What is the age range between which 95% of typically developing children start to walk?
9-17 months!
72
By what age does a child's gait have the approximate appearance of an adult's (eg heel strike)?
3 years
73
What are the five main domains of development?
```
Gross motor
Fine motor
Communication (expressive and receptive)
Personal-Social
Problem solving (aka cognitive, adaptive, self-help)
```
74
A toddler prefers standing to sitting. What concern should lead you to characterize this more fully?
May do so because of abnormally tight muscles, possibly due to a neuromuscular disorder.
75
What information does, "Does your toddler have a favourite toy?" elicit?
Demonstration of an intense interest in one "toy" or object to the exclusion of others is atypical at this age and may be symptom of an underlying developmental disorder.
76
When does handedness develop?
18-24mo; appearance of hand preference before this might indicate contralateral weakness, and should be investigated
77
What simple rule of thumb guides assessment of expressive language?
sentence length equals age in years
1yo: several single words
2yo: simple, two-word sentences
3yo: uncountable number of words in sentences three words long or longer
78
Why ask if a toddler gets along with family members?
Difficulty or lack of interest are both concerning & require further evaluation
79
When do children start imitating adult activities (cleaning, cooking)?
around 18mo
Lack of interest is atypical
80
What is one question you can you ask to assess regression?
"Are there any skills that it seems like your child had developed and then lost?"
81
What is the most variable component of development?
Language
| Tell parents this!
82
Which is a better indicator of long-term language outcomes?
Receptive language (though most of our tools assess expressive)
83
What is the prevalence of autism spectrum disorder?
1 in 68 (1.5%)
84
What is autism spectrum disorder?
developmental disorder characterized by
- differences in social communication and interaction
- restricted or repetitive behaviours, interests, or activities.
85
When should screening take place for autism spectrum disorder?
18mo and 24mo
86
Name 4 conditions that are more common among premature infants that are risk factors for developmental delay
Bronchopulmonary dysplasia
Retinopathy of prematurity
Hyperbilirubinemia
Periventricular leukomalacia
87
If you see two dots connected by a horizontal line on a growth curve, what does that likely mean?
Plotting both chronological and corrected age
88
By what age should the Babinski reflex disappear?
Around when the child starts walking, but definitely by 2y
89
What are some signs of hypotonia in an infant or toddler?
Slumped posture, poor head control, pt slipping through hands when held under armpits
90
What is a circle, on a pedigree?
Female
91
What is a square, on a pedigree?
Male
92
What is a triangle, on a pedigree?
Spontaneous abortion (with a line through it indicates termination of pregnancy)
93
What does a line through a square, circle, or triangle mean, on a pedigree?
Death
Square or circle with SB underneath: stillbirth
Triangle: termination of pregnancy
94
What is the likeliest diagnosis for an ex-29-week preemie with delayed developmental milestones and hypertonia and spasticity on exam?
CP
95
What is spasticity?
Velocity-dependent increased muscle resistance
96
What is a sign of increased calf tone? What would you assess?
Toe-walking
Assess dorsiflexion
97
What hand posture is a sign of CNS dysfunction (when held persistently beyond the first few months of life)?
Persistently closed hands
| Thumb held in palm
98
What are the types of CP?
```
Spastic quadriplegia
Spastic diplegia
Spastic hemiplegia
Dyskinetic
Ataxic
```
99
What is the general pattern, classic etiology, and clinical scenario for the CP subtype spastic quadriplegia?
General pattern: Entire body
Classic etiology: Global brain abnormalities
Common clinical scenario: Various
100
What is the general pattern, classic etiology, and clinical scenario for spastic diplegia (CP subtype)?
General pattern: Legs more affected than arms
Classic etiology: Periventricular WM abnormality
Common clinical scenario: Premature infants
101
What is the general pattern, classic etiology, and clinical scenario for dyskinetic CP?
General pattern: Variable, often entire body
Classic etiology: Basal ganglia, cerebellum, and/or thalamus
Common clinical scenario: perinatal asphyxia, kernicterus
102
What is the general pattern, classic etiology, and clinical scenario for spastic hemiplegia (CP subtype)?
General pattern: Unilateral arm & leg
Classic etiology: Unilateral UMN abnormality
Common clinical scenario: Stroke
103
What is the general pattern, classic etiology, and clinical scenario for ataxic CP?
General pattern: Entire body
Classic etiology: Cerebellar abnormalities
Common clinical scenario: Cerebellar hypoplasia, pontocerebellar hypoplasia
104
What is cerebral palsy?
Heterogenous group of nonprogressive disorders
| Characterized by motor and postural dysfunction
105
True or false: children raised bilingual have slower language development than children raised monolingual
Mixed: Bilingual children may start somewhat later, but first words should still appear within the normal age range
106
How many words should bilingual children be able to speak by 20mo?
20 words from both languages combined
107
By what age do bilingual children use their languages separately?
4y
108
What is the biggest single risk factor for CP?
Prematurity
| 78% of children with CP were premature
109
What is the general initial workup for CP?
Detailed H&P
Screening
Neuroimaging
Developmental testing
110
Why is a detailed history & physical important in the initial evaluation of CP?
1) determine that the condition is static (not degenerative or progressive), and 2) classify the type of CP
111
What kinds of screening should be done in children with CP?
```
Developmental
Ophthalmologic
Hearing
Speech and language
Oral-motor function
```
112
What additional testing might you consider in working up suspected CP, and why?
If features of epilepsy: EEG
If
- features suspicious for metabolic or genetic disorder, or
- no structural abnormalities on imaging
Metabolic and genetic testing
113
When should a child with intellectual disability get chromosomal testing?
Most experts recommend chromosomal testing in all children with intellectual disability. (American site, but still)
