Uworld-pediatrics study notes PDF

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study notes for peds!...

Description

Differential*diagnosis*of*stridor*in*infants*&*children* Distinguishing*Features* Most!common!from!age!6!months!to!6!years! Associated!with!“barky”!cough,!fever,!rhinorrhea!&!congestion! Stridor!most!severe!at!age!4-8!months! Persistent!stridor!that!worsens*in*supine!position!&!improves!in!prone!position! Stridor!caused!by!laryngotracheal!foreign!bodies!has!acute*onset! Associated!with!moderate-to-severe!respiratory!distress! Presents!before!age!1!year! Persistent!stridor!that!improves*with*neck*extension! Associated!with!cardiac!abnormalities!(50%)!

Diagnosis* Croup* (Laryngotracheobronchitis)* Laryngomalacia* Foreign*body*aspiration* Vascular*Ring*

! Croup*(laryngotracheitis)* Parainfluenza!viral!infection!–!inflammation!of!larynx!&! trachea! Age!6!months!to!3!years! Fall,!early!winter! Inspiratory!stridor! “Barky”!seal-like!cough! Hoarse!voice! Mild!(no!stridor!at!rest:!corticosteroids)! Moderate/severe!(stridor!at!rest):!corticosteroids!+! nebulized!epinephrine!

Pathogenesis* Epidemiology* Clinical*Features*

Treatment*

! Diagnosis* Laryngotracheitis*(croup)*

Key*respiratory*tract*infection*in*children* Classic*pathogen* Parainfluenza!virus! -

Epiglottitis*

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Haemophilus,influenza,

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Bronchiolitis*

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Respiratory!Syncytial! Virus!

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Presentation* Age!6!months!to!3!years! “Barky”!coughing,!stridor,! hoarse!voice! Unvaccinated!children! Sore!throat,!dysphagia,! drooling,!“tripod!position”! Age!7%* Assess!for!motor!dysfunction! Assess!for!lactation!failure! Daily!weights! Consider!formula!supplementation!

! Diagnosis* Erythema*Toxicum*Neonatorum*

Neonatal*HSV*

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!

Neonatal*Varicella*

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SSSS*

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Neonatal*Rashes* Clinical*Presentation* Asymptomatic!erythematous! macules,!papules,!and!pustules! throughout!the!body! Three!patterns:! Vesicular!clusters!on!skin,!eyes,! &!mucus!membrane! CNS!Infection! Fulminant,!disseminated! multiorgan!disease! Fever,!ranges!from!vesicular! clusters!on!skin!to!fulminant,! disseminated!disease! Fever,!irritability!&!diffuse! erythema!followed!by!blistering! &!exfoliation,!positive* Nikolsky’s*sign!

Treatment* -

None!

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Acyclovir!

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Acyclovir!

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Oxacillin,!Nafcillin,!or! vancomycin!

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! ! Diagnosis* * * Transient*Tachypnea* of*the*Newborn*

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*

Respiratory** Distress*Syndrome* L:S*>3*fetal*lung* maturity*

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* Persistent*pulmonary* Hypertension*

Common*Causes*of*neonatal*respiratory*distress* Pathophysiology* Clinical*Features* Inadequate!alveolar!fluid!clearance! Tachypnea!that!begins!shortly!after!birth!&! at!birth!results!in!mil!pulmonary! resolves!by!day!2!of!life! CXR:!Bilateral!perihilar!linear!streaking! edema! Surfactant!deficiency!results!in! alveolar!collapse!&!diffuse! atelectasis! (premature!neonates!with!very!low! birth!weight)! High!pulmonary!vascular!resistance! results!in!right!to!left!shunting!and! hypoxia!

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Severe!respiratory!distress!&!cyanosis!after! premature!birth! CXR:!Diffuse,!reticulogranular,!ground-glass! appearance! Air!bronchograms! Low!lung!volumes!!!!!Tx:!CPAP**! Tachypnea!and!severe!cyanosis! CXR:!Clear!lungs!with!decreased!pulmonary! vascularity!

! ! Diagnosis* * Marfan’s*Syndrome*

* Homocystinuuria* Tx:*B6,*B12,*and*Folate*to*lower* homocysteine*levels*

Differential*Diagnosis*for*Marfanoid*Habitus* Distinguishing*Features* AD! Normal!intellect! Superotemporal*lens! dislocation! Aortic!root!dilation! AR! Intellectual*disability* Inferomedial*Lens* dislocation* Thrombosis*(CVA)! Megaloblastic!anemia! Fair!complexion!

Overlapping*Features* ! Pectus!Deformity! Tall!Stature! é!Arm:!Height!Ratio! ê!Upper:!Lower!segment!ratio! Arachnodactyly! Joint!hyperlaxity! Scoliosis*

! Definition* Workup* * * * Management*

Monosymptomatic*(isolated)*Enuresis* Urinary!incontinence!in!children!>!5! Urinalysis! Urologic!imaging!for!children!with!significant!daytime!symptoms!&!history!of!recurrent!UTI! Behavior!Modification! Avoid!sugary/caffeinated!beverages! Void!regularly!during!the!day!&!immediately!before!bedtime! Drink!ample!fluids!in!the!AM!&!early!afternoon,!minimize!fluid!intake!before!bedtime! Reward!system!(eg,!“gold!star!chart”)! st Enuresis*alarm:!1 !line!intervention!when!behavior!modification!fail;!best!long-term!outcome! Pharmacotherapy:!Best!for!short-term!improvement;!high!risk!of!relapse! st 1 !line:!Desmopressin! nd 2 !line:!TCA!

! Etiology* Psychological*stress* Urinary*tract*infection* Diabetes*mellitus* Diabetes*Insipidus* Obstructive*sleep*Apnea*

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Causes*of*secondary*enuresis* Associated*Symptoms* Behavior!regression,!mood!lability! Dysuria,!hesitancy,!urgency,!abdominal!pain! Polyuria,!polydipsia,!polyphagia,!weight!loss,!lethargy,!candidiasis! Polyuria,!polydipsia! Snoring,!dry!mouth,!fatigue,!hyperactivity,!irritability!

! !

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Pathophysiology* Clinical*Presentation*

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Diagnosis*

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Management*

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Layngomalacia* Increased!laxity!of!supraglottic!structures! Inspiratory*stridor* Worsens!wen!supine,!crying!or!feeding! Improves!in!prone!position! Begins!in!the!neonatal!period,!peaks!at!age*4-8* months!resolves!by!age!12-18!months! Flexible!laryngoscopy!showing!collapse!of!supraglottic! structures!with!inspiration!*!omega!shaped!epiglottis! Reassurance!for!most!cases! Supraglottoplasty!for!sever!symptoms!(eg!poor!weight! gain,!apnea,!cyanosis,!rapidly!worsening!stridor)!

! Increased*estrogen* production*or*peripheral* conversion*

Androgen*deficiency*

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Common*pathological*causes*of*gynecomastia* Testicular,!adrenal,!or!human!chorionic!gonadotropin-secreting!tumors! Cirrhosis!or!malnutrition! Thyrotoxicosis! Congenital!excessive!aromatase!activity! Androgen!use! Drugs!(eg,!spironolactone,!cimetidine,!herbal!products!(eg,!tea!tree!oil,!lavender!oil)! Primary!or!secondary!male!hypogonadism!(eg,!Kleinfelter’s!syndrome,!testicular! damage)! Hyperprolactinemia! Renal!failure!

!

Risk*factors*

Diagnostic*Criteria*

Subtypes*

Management* Prognosis*

Febrile*seizure* Fever!from!mild!viral!(eg!influenza,!adenovirus,!HHV-6)!or!bacterial!infection! Immunizations!(DTaP,!MMR)! Family!history! Age!6mos!–!6!years! Temperature!>38C!(100.4F)! No!history!of!previous!afebrile!seizures! NO!CNS!infection! No!acute!systemic!metabolic!cause!of!seizure! Simple:* Non-focal!(tonic-clonic!or!atonic)! 1!episode!30!minutes! Abortive!therapy!if!seizure!>5!minutes! Reassurance/education! Normal!development/intelligence! ~30%!Risk!of!Recurrence! 40.5!(105F)!within!2!days! Hypotonic!hyporesponsive!episode!within!2!days! epilepsy,!infantile!spasms)! Inconsolable,!persistent!crying!within!2!days! Encephalopathy!within!a! week!of!previous!vaccine! does! ! ! Kawasaki*Disease* Patient!should!have!fever!for!≥!5!consecutive!days!as!well!4!out!of!5! 1. Conjunctivitis:!Bilateral,!non!exudative,!spares!limbs! 2. Oral*mucosal*changes:!erythema,!fissured!lips,!“strawberry!tongue”! 3. Rash* 4. Extremity*Changes:!Erythema,!edema,!desquamation!of!the!hand!and!feet,!usually!the!last!manifestation! 5. Cervical*lymphadenopathy!≥!1.5!cm!usually!unilateral,!least!consistent!finding!(present!in!80! OR! Patient!successfully!quit!smoking!for!>15!years! OR! Patient!has!other!medical!problems!that!significant!limitlife!expectance!or! ability/willingness!to!undergo!lung!cancer!surgery!

!

Arm*Position*

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Shoulder*Dislocation* Anterior*Shoulder*Dislocations* External!rotation!and!slight!abduction!

Neurovascular* compromise* Classic*Scenario*

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Axillary*artery*&*nerve!at!risk!

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Physical*Exam*

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Blow!to!abducted,!externally!rotated!extended! arm!(blocking!!a!basketball!shot)! Prominent!acromion!(if!thin!patient!hand!loss!of! shoulder!roundness)!

!

! ! ! ! ! ! ! !

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Posterior*Shoulder*Dislocation* Internal!rotation!and!adduction! Unable!to!externally!rotate! Unusual! Blow!to!anterior!shoulder! Seizure!!and!electrocution! Posterior!prominence!and!anterior! shoulder!is!flat!

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MSK*Injuries* Fall*on*outstretched*arm*à *snuffbox*tenderness* Anterior*shoulder*dislocation* th

Fracture*of*the*5 *metacarpal*neck* Humerus*Fracture* Hip*Fracture* Femur*fracture* Tibial*fracture* Pelvic*Fracture*

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AVN!(scaphoid)! Axillary!nerve!injury!

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Abscess!from!bite!wound! Radial!nerve!injury! DVT! Avascular!necrosis! Severe!blood!loss! Fat!embolus! Compartment!Syndrome!! Hypovolemic!Shock!

! Screening*tests*for*patients*at*average*risk** Age*

Disease* Breast*Cancer* Cervical*Cancer*

Women!50—75! Women!21-65!

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Test*&*Interval*

Mammogram!every!2!years! Pap!smear!every!2!years!

Colon*Cancer* 50-75! FOBT!yearly!or!colonoscopy!every!10!years! 15-65! HIV!Antivody!screen!1!time! HIV* Men!35+! Lipid!panel!every!5!years! Hyperlipidemia* 18+! Blood!pressure!measurement!every!2!years! Hypertension* Osteoporosis* Women!65+! ! *Optimum!screening!test!&!intervals!may!vary!for!patients!at!increased!risk!or!for!those!with!abnormal!or!near!abnormal! results! !

! !

!

Dyslipidemias*

Protein*Defect*

Familial* hyperchylomicronemia* (Type*1)*

LPL! APO!C2!

Familial* hypercholesterolemia* (Type*2a)*

LDL!Receptor! Apo!B100!

Familial* dysbetalipoteinemia* (Type*3)*

Apo!E!

Familial* hypertriglyceridemia* (Type*4)*

Apo!A-V!

Elevated*Lipoproteins*

Major* Manifestations* Acute*Pancreatitis* Chylomicrons! Lipemia*retinalis* Eruptive!skin!xanthomas! Hepatosplenmegaly! LDL! Premature* coronary* artery*disease* Corneal!arcus! Tendon!xanthomas! Xanthelasmas! Chylomicron! and! VLDL! Premature! coronary! remnant! artery!disease!&! Peripheral! vascular! disease! Tuboeruptive! palmar! xanthomas! Increased* pancreatitis* VLDL! risk* Associated! with! obesity! and!insulin!resistance!

!

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Epidemiology* Pathogenesis* Clinical*Features*

Diagnosis*

Treatment*

Minimal*Change*Disease* MCC!of!nephrotic!syndrome!in!children! Median!age!2-3;!85%!of!cases!occur!before!10!years!of!age! T-Cell!mediated!injury!to!podocytes!causes!increased!molecular!permeability!to!albumin! Majority!of!cases!are!idiopathic! Edema! Fatigue! No!hematuria! Proteinuria! Hypoalbuminemia! Renal!biopsy!without!microscopic!changes! Corticosteroids!

! ! Pathogenesis* Clinical* manifestation*

Laboratory* Findings* Diagnosis* Treatment*

Henoch-Schonlein*purpura* IgA-mediated!leukocytoclasic!vasculitis! Boys,!fall!and!winter!months,!may!present!with!testicular!pain***! Palpable!purpura!(MC!symmetrically!over!lower!legs,!buttocks,!and!arms)! Arthritis/arthralgia!(Knees!and!ankles)! Colicky*Abdominal!pain/!intussusceptions! Renal!disease!similar!to!Ig-A!nephropathy! Normal!platelet!count!&!coagulation!studies! Normal!to!Increased!Creatinine! Hematuria!+/-!RBC!Casts!+/=!proteinuria! Renal!biopsy!will!demonstrate!deposition*of*IgA*in*the*mesangium! Supportive!(hydration!&!NSAIDS)!for!most!patients! Hospitalization!&!systemic!glucocorticoids!in!patients!with!severe!symptoms!

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! !

Potter*Sequence* ↓* Urinary!Tract!Anomaly!

!

Anuria/oliguria!in!utero! Oligohydramnios!(AFI!5!WBCs/hpf)!and!bacteriuria!(50,000!colony-forming!units/mL)!à!undergo!anatomic! abnormalities! Recurrent!UTIs!in!children!of!any!age! UTI!in!a!child!of!any!age!with!a!family!history!of!renal!or!urologic!disease,!hypertension,!or!poor!growth! Children!who!do!not!respond!to!appropriate!antibiotics!treatment!

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!

Epidemiology*

Clinical*Features*

Diagnosis* Treatment*

Acute*lymphoblastic*leukemia* MC!childhood!cancer! Peak!age:!2-5!years! Make!>!female! Nonspecific!systemic!symptoms! Bone!pain! Lymphadenopathy! Hepatosplenomegaly! Pallor!(from!anemia)! Petechiae!(from!thrombocytopenia)! BM!Biopsy!with!>!25%!lymphoblast! Multi-drug!chemotherapy!

! Grade* I* II* III* IV* V* -

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Vesicoureteral*Reflux* Description* Into!a!non-dilated*ureter! Into!the*pelvis*&*calyces!without!dilation!

Mild*to*moderate*dilation*of*ureter,*renal*pelvis*&*calyces,!with! minimal!blunting! Moderate!ureteral!tortuosity!&!dilation*of*the*pelvis*&*calyces! Gross*dilation*of*the*ureter,*pelvis*&*calyces;!loss!of!papillary! impression;!ureteral!tortuosity! VUR!–!retrograde!flow!of!urine!from!the!bladder!up!into!the!ureter!and!renal!pelvis.! VUR!MC!pediatric!urologic!problem.!It!is!a!risk!factor!for!recurrent!UTIs,!which!in! turn!place!a!patient!at!significant!risk!for!renal!scarring.!The!growing!kidney!is! particularly!prone!to!scarring!renal!insufficiency,!and!end-stage!renal!disease.! Gold!standard!modality!of!diagnosing!VUR!is!a!voiding*cystourethrogram.! Renal*and*Bladder*ultrasound*to*evaluate*for*anatomic*abnormalities*that*might* predispose*to*VUR.! -

! Risk*Factors*

Clinical*Presentation*

Complications*

Treatment*

Constipation*in*Children*à *Oral*laxative*therapy* - Initiation!of!solid!food!&!cow’s!milk!(transition!from!breast!milk)! - Toilet!training! - School!entry! - Recurrent!cystitis***! - Straining!with!passage!of!hard!stools! - Crampy!abdominal!pain! - !65%!in!term!infants! Increased!erythropoiesis!from!intrauterine!hypoxia! Maternal!diabetes! Maternal!HTN! Smoking! IUGR! Erythrocyte!transfusion! Delayed!cord!clamping! Twin-twin!transfusion! Ruddy!skin! Hypoglycemia! Respiratory!distress! Cyanosis! Apnea,!irritability,!jitteriness! Abdominal!distension! Partial!exchange!transfusion!(remove!blood,!infuse!normal!saline)!

! Acquired*Aplastic* Anemia* Drugs!(NSAIDS,! Sulfonamides)! Benzene,!glue! Idiopathic! Viral!(HIV,!EBV)! Immune!Disorders!

Clinical*Manifestations*of*Fancon’s*Anemia* Bone*Marrow*

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Aplastic!anemia,!and!progressive!BM!failure!

Appearance* Skin*

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Eyes/Ears*

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Short!Stature,!microcephaly,!abnormal!thumbs,!and!hypogonadism! Hypopigmented/hyperpigmented!areas,!cause!au!lait!spots,!and! large!freckles! Strabismus,!low!set!ears,!and!middle!ear!abnormalities!(eg,! hemorrhage,!incomplete!development,!chronic!infection,!deafness)!

Thymoma! ! ! !

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Signs*of*Deliberate*Scald*Injury* Intentional!immersion! Linear!demarcation!with!no!splash!marks! Extensive!burns!to!back!and!buttocks! Doughnut!pattern! Sparing!of!flexural!creases!(“zebra”!pattern)!

! Pathology* Clinical* Features*

Treatment*

• • -

Coarctation*of*the*Aorta* Thickening*of*tunica*media*of*aortic*arch!near!the!ductus!arteriosus! Hypertension!in!UE! ↓Perfusion!to!LE! ↓Post-ductal!oxygen!saturation! ↓Femoral!Pulses! Lower-extremity!claudication! Heart!failure!(irritability,!poor!feeding,!diaphoresis);!cardiogenic!shock!(infants)! Palpable!pulsations!of!intercostal!vessels!(adults)! Surgical!Repair!

! ! *

Pertussis*treatment*&*post-exposure*prophylaxis** * for*all*close*contact* Azithromycin!x!5!days! Age*1*month* OR! Erythromycin!x!14!day!

*

Cause* Withdrawal*of*estrogen*

Trauma*

Malignancy*(eg,* rhabdomyosarcoma)*

Prepubertal*vaginal*bleeding* Fey*Features* Presents!in!neonatal!period! Lasts!38! [100.4]! or! Present*in** hypothermia!*50%*of*cases* Poor!feeding! Irritability!or!lethargy! Present*in** Respiratory!distress! Vomiting! 25-50%*of*case* Seizures! Jaundice! Apnea! Present*in** Cyanosis! 10!days!without!improvement! OR! Severe!symptoms,!fever!>!39!(102F),!purulent!nasal!discharge,!or!face!pain!>3!days! OR! Worsening!symptoms!>!days!after!initially!improving!viral!URI.! S.!Pneumoniae,!Haemophilus!influenza,!and!Moraxella!catarrhalis!are!the!most!commonly!implicated!organisms.! ! Bacterial*meningitis*in*children*age*>*1*month* Clinical* Features*

Fever! Continuing/poor!feeding! Seizures! Altered!mental!status!(lethargy,!irritability)! Nuchal!rigidity,!Kerning!&!Brudzinski!sign! Bulging!anterior!fontanelle! CBC!&!electrolytes! Workup* Blood!cultures! LP!&!CSF!studies! History!of!hydrocephalus!or!neurosurgical!procedure! Indication*for* imaging*prior*to*LP* History!of!head!trauma! Coma!or!focal!neurologic!findings! Treatment* Intravenous!vancomycin!&!Ceftriaxone!OR!Cefotazime! Dexamethasone!for!Haemophilus,influenza!type!b!meningitis! Answer:*LP*followed*by*antibiotics* ! ! !

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Acute*Cervical*Adenitis*in*Children* Location*

Pathogen*

Unilateral!

Staphylococcoal,aureus, Streptococcus,pyogenes, Anaerobic!bacteria! (eg,,Prevotella,buccae), Bartonella,Henslae, Mycobacterium,avium, Adenovirus! ABV/CMV!

Bilateral!

Additional*Features* -

Pronounced!erythema,!tenderness!

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Dental!caries,!periodontal!disease!

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Papular!nodular!at!side!of!cat!scratch!or!bite! Gradual!onset,!non-tender! Phayngoconjunctivitis! Mononucleosis!

! Type* Microbiology*

Clinical*Features*

Treatment*

-

Impetigo* Non-Bullous* Staphylococcus,aureus, Group!A,Streptococcus,! (S,Pyogenes)! Painless!non-pruritic!pustules!! Honey!crusted!lesions!

Bullous* -

S!aureus!

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Rapidly!enlarging!flaccid!bullae!with! yellow!fluid! Collarets!of!scale!at!periphery!of!lesion! Limited!Skin!Involvement:!Topical!antibiotics!(eg,!mupirocin)! Extensive!skin!involvement:!Oral!antibiotics!(eg,!cephalexin,!dicloxacillin,!clindamycin)!

! Epidemiology* Clinical* Features*

Late*Sequelae* Prevention*

Acute*Rheumatic*Fever* Peak!incidence:!Age!5-15! Twice!as!common!in!girls! Major* Joints!(migratory!arthritis)! (Carditis)! Nodules!(subcutaneous)! Erythema!marginatum! Sydenham!Chorea! Fever! Minor* Arthralgias! ↑ESR/CRP! Prolonged!PR!Interval! Mitral!regurgitation/stenosis! Penicillin!for!group!A!streptococcal! (Streptococcus,pyogenes)!pharyngitis!

! Clinical*Findings*of*congenital*infection* IUGR! Hepatosplenomegaly! Jaundice! Blueberry!muffin!spots! Periventricular!calcification! Cytomegalovirus* Diffused!intracerebral!calcification! Toxoplasmosis* Severe!choioretintis! Rhinorrhea! Syphilis* Abnormally!long-bone!radiographs! Desquamating!or!bullous!rash! Cataracts! Rubella* Heart!defects!(eg,!PDA)! All*

! ! ! ! ! !

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Clinical*triad*

Diagnosis* Prevention*

Congenital*Rubella*Syndrome* Cataracts!or!glaucoma! Sensorineural!hearing!loss! Congenital!heart!disease!(eg,!Patent!ductus!Arteriosus)! Rubella!IgM! Polymerase!chain!reaction!testing! Maternal!immunization!with!live!attenuated!rubella!vaccine!prior!to!conception!

! Non-Bullous*Impetigo* Staph!aureus! Group!A!beta!hemolytic!streptococcus,(S, Pyogenes)! Painful!non!itchy!pustules!&!honey!crusted! lesions! Topical!antibiotics!(eg,!mupirocin)! Post-streptococcal!glomerulonephritis!

Microbiology*

Clinical*Features* Treatment* Complications* !

Cat-scra...