Peds exam

pediatric developmental considerations

-lipase not secreted til 1 (only breast milk no cows)

-no need for solid foods until 4 months

-infants stomachs empties every 2.5-3 hrs

rectal atresia

complete closure of anal passage

-immediate surgical intervention

tx: manual dilators

rectal stenosis

narrowing of the rectal passage way

-ribbon like stools

tx: manual dilators

imperforate anus

no rectal opening, fistulas may go to other systems

pyloric stenosis

-thickening muscle causing a blockage (3-6 wks old)

S/S: projectile vomiting, olive shaped mass (RUQ), hungry after vomiting

-diagnoises by US, gradual feedings 6 hrs after surgery, can go home within 24 hrs

-lack of tears when crying means dehydrated

intussusception

-telescoping portion of the intestines (commonly ileocecal valve)

S/S: jelly stool, sausage shaped mass RQ, intermittent colicky pain, fever

-barium or air enema (is diagnosis and tx), stooling means fixed,

-high reoccurrence rate

appendicitis

inflammed appendix

S/S: pain in RLQ, umbilical pain , Mcburneys point (rebound pain, doesnt hurt with pressure when pressure is gone hurts),

-no heat packs to prevent perforation

-6-10 average age

-if pain stops emergency

-dont give pain meds until after diagnosis

rotavirus

explosive, watery, pale, malodorus

E. Coli

green and watery

salmonella

bloody

constipation causes

-kids want to keep playing not poop

GER vs GERD

GER: functional reflux; peaks at 4 months, happy spitters

GERD: pathological reflux, chocking, apnea, poor weight gain

-no treatment needed if no weight loss, thickened formula (crosscut nipples), lactose-free formula, smaller frequent feeds slower, no vigourus play, feed upright, add cereals and rice

Hirschsprung Disease

-aganglionic megacolon

-absense of ganglion cells resulting in lack of motility

S/S: constipation or explsovie BM, foul smelling, ribbon-like stools

diagnosis: rectal biopsy (loooking for ganglion cells, if none have disease)

urinary tract infection

cystitis: starts distal

pyelonephritis: upper tract infection

diagnosis: urine culture and sensitive (takes 48-72 hrs to get back), straight cath if under 2

-VCUG (voiding cystography)

glomerulonephritis

inflammation of glomeruli

-caused by STREP infection

S/S: gross hematuria, oliguria, periorbital edema, HTN, HA, ascites

tx: monitor hypoNA (seizure precautions), monitor I&Os, urine volume and character, daily weights, neuro assessments

Nephrotic syndrome

-excessive proteinuria causing hypoalbuminea, and hyperlipidemia

S/S: edema (periorbital, facial, extremities), decreased output, HTN, weight gain, V/D, growth failure

cryptorchidism

-undescended or ectopic testicles

-common, unilateral Right

-may descend spontaneously within first 3 months of life

-surgery at 6-12 months (monitor cancer long term)

testicular torsion

-SURGICAL EMERGENCY (withing 4-8 hrs)

-neonates: dusky scrotum, no pain, spontaneously

-older males, painful, trauma/excertion, fever

end of life

-pt may exhibit regression

-preschoolers are magicaal thinkers dont say “going to sleep”

-8-9 understands death is permanence

end of life: Cheyne-Stokes, loss of sense, decreases vital signs, appetite, confusion, incontinence, seizures

Coarctation of the Aorta

-narrowing of strictures of the descending aorta distal to the carotid arteries

S/S: increased BP upper extremities, decreased BP lower extremities

-watch for rebound hypertension after tx

Tetralogy of Fallot

-pulmonary stenosis, right ventricular hypertrophy, overriding aorta, ventricular septal defect

S/S: tachypnea, dyspnea of excertions, growth failure, cyanosis after DA closure, loud systolic ejection murmur (harsh and radiating),

TET spells:

-imbalance between pulmonary and systemic vascular resistance causing decreased pulmonary flow and increased right to left shunting

S/S: rapid deep breathing, deepeing cyanosis, decreased intensity of murmur, limpness, convulsion, death is rare

-goal is to increase pulmonary blood flow and decrease shunting and spasms, position in knee to chest/tripod position, O2 100%, fluids, morphine, BB

Heart failure

-heart not able to main cardiac demands efficient for the bodys needs

infants S/S: poor growth and development, poor feeds, irritability, SOB, FTT, peripheral edema

child S/S: poor growth, SOB and exercise intolerance

-cardiac cath gold standard diagnostic but invasive

tx: digoxin (positive inotrope, increases contractility); hold if infant HR under 90, child HR under 70,

toxicity: bradycardia, dysrhytmias, N/V, anorexia

-giver every 12 hrs, dont double dose

Rheumatic Fever

-caused from STREP

-effects heart, joints, subQ tissue, nervous system

tx: long term antiboitics and aspirin

Major: Subcutaneous Nodules, Carditisis/valvitis, Arthritis, Rapid movement (Sydenham chorea), Erythema marginatum

Minor: fever, arthaligia, increased ESR and C-protein, long PR intervals

Kawasaki Disease

-self limiting systemic inflammatory disease causing multisystem vasculitis

tx: high dose aspirin

C:conjunctivitis

R: rash

A; adenopathy

S: strawberry tongue

H: hands and feet swollen

F:fever

Stage 1: CRASH F, fever over 104

Stage 2: cracked lips, peeling skin and tips of fingers and toes, joint pain

stage 3: lingering inflammation

how infants airways are different

-narrow airway

-belly breathers til 6

-epiglottis is long and flaccid until age 8 (higher chocking and aspiration risk)

-kids are more likely to loss airway from inflammation

-neck has fewer muscles

-lung development complete by 5/6, right bronchus shorter, wider, and more vertical

-more likely to aspirate into the right bronchus

Health history

-6-8 colds per year is average

mild respiratory distress

tachycardia, tachypnea, diaphoresis

-intercostal and ribs retractions

moderate respiratory distress

nasal flaring, retractions, grunting, wheezing, anxiety, irritability, mood changes, HA, HTN

-substernal and subcostal; lower dome form by diaphragm

severe respiratory distress

bradycardia, stupor/coma, cyanosis, apnea/ALTE, head bobbing

-supraclavicular and supresternal

Esophageal atresia

failure of esophagus to develop continuous passage to stomach (blind pouch)

-OGT/NGT in blind pouch low suction for decompression, suction frequnetly

Tracheoesophageal fistula

portion of esophagus is connected to the trachea by a fistula causing abnormal communications between the two strictures

-NO BARIUM

croup

-can be viral of bacterial

-upper airway inflammation/swelling

-affects larynx, trachea, and bronchi

-edema of lateral walls of trachea below the vocal cords

viral croup

acute laryngotracheitis, spasmodic croup, laryngitis

-can manage at home; supportive care, cool mist vaporize, steroids, fluids and pain

acute laryntracheitis

-viral

-peaks 3-26 months

-URI

-seal-like bark, worse at night

spasmodic croup

-viral

-3-36 months peak

-no URI

-sudden onset at night with barky cough

laryngitis

-viral

-more common older children

-hoarseness

bacterial croup

bacterail tracheitis, epiglottitis, laryngotracheobronchitis (LTB)

-monitor 02, abx, nebulizers, atroids

bacterail tracheitis

-progressive illness over 5 days

-can lead to narrowing airway

-high fever 102.2, croupy cough, thick purulent secretions, hoarseness

epiglottitis

-MOST LIFE THREATENING
-peak 1-5 yrs

-rapid progression

-4 D’s: dysphonia, dysphagia, drooling, distressed respiratory efforts

-TRIPOD position

-avoid throat inspections/cultures, control airway, do IV after airway is complete

-”thumb sign” on xray

-Hib vaccine can prevent this

laryngotracheobronchitis (LTB)

-acute onset,

-high fever 102,2, barky seal cough, hoarseness, stridor and resp distress

-cxr can show “ steeple sign”

bronchiolitis/RSV

-fever, cough, dehydration, resp. distress

-this is viral dont give abx

-droplet preccautions

-RSV vaccine avaible saved for at risk babies (preterm/ moms without vaccine)

-annual epidemics oct-mar

-IV steroids/oral steroids (decrease inflammation), humidified 02, isolation precautions/droplet

Pertussis (whooping cough)

-highly contagious lung infection

-can be deadly to infants (highest risk under 3 months)

1) Catarrhal stage: mild cough low grade fever

2) paroxysmal stage: whooping cough

3) convalescent stage: cough is going away

-droplet precautions, remove 5 days after w/ abx, remove 3 weeks after cough in no tx

asthma

triggers: environment, viral illnesses, BPD (bronchopulomary dysplasia), exercise, emotions, weather changes

-trigers tha activates IgE antibodies

S/S: bilateral wheezing

-acute status asthmaticus: PICU, may needCPAP/vent, IV mag, emergent cant break refractory, need albuterol

-nighttime cough is beyond mild, it is persistent

-montelukast medicine: ticks and suicide are SE

-IV mag muscle smooth relaxers

-laba need inhaled corticosteroid first

-not all wheezing is asthma

foreign body aspiration

-blockage of resp. passage way with fluids or semi solids

S/S: inspiratory stridor, unilateral wheezing, drooling

tx: forceful cough, heimlich maneuver, bronchoscopy

viral vs bacterial

viral: self-limiting, supportive care, often at home, fluids, rest, tyelonol

bacterail: needs abx, fluids 02, pain fever

iron deficiency anemia

-decreased iron supply (most common, microcytic, hypochromic; small and pale RBCs)

-iron is needed to make Hgb,decreased O2 carrying capactity of blood

S/S: mild: asymptomsttic, SOB, tachy during excertion

moderate: SOB, tachy, dizzy, palpitatinons, fatgieu, PICA

severe: murmur, CHF, enlarged spleen

tx: breat milk or Fe formula, elemental iron supplements; give on empty stomach with vit. C juice, dont give with milk or tea, use straw/dropper and rinse mouth (will stain teeth, make poop black and tarry)

-lead poisoning can be a cause; more common in preemies 6-12m

-ferritin (gol standard) looks at iron stories

sickle cell disease

autosomal recessive genetic trait

emergencies: cerebreal vascualr accident (CVA), acute chest syndrome (ACS), splenic sequestration and infection

tx: maintain good oxygenation, hydrate, pain management

diagnosis: newborn screening (all 50 states)

-fever requires immediate medical attention, provide pain management (home NSAIDS/tylenol, hospitals PCA/toradol)

vaso-occlusive crisis: can occur anywhere on body; PAIN and soft tissue swelling

-hydration pain managemtn

infection

-all fever in neutropneic life threaneing

-ANC less than 500 severe

ANC less than 1500 mild

-no rectal temps

-abx within an hour

leukemia

-proliferation of abnormal blood cells in the body; stem cells are bone marrow produce immature WBC (blasts)

-most common cancer in children under 14

S/S: fever, bone pain (refuse to walk), enlarged liver or spleen, increased lymphadenopathy, mimic of cold and flu symptoms

-persistence of symptoms is key

diagnosis: bone marrow biopsy/ aspiration (gold standard)

Diabetes Insipidus

-hypofunction of the posterior pituitary gland

-neuro or nephro genic

S/S: saturadted diapers, fussy, irritable, polyuria, polydipsia, enuresis, assess for hyperatremia (seizures)

-lots of dilute urine (HYPERatremia)

Syndrome of Inappropraite antidiuretic hormone (SIADH)

-excessive levels of ADH produced

S/S: N/V, seizures, cramping, LOC changes, fluid retention, HA, lethargy (seizure precautions)

-high urine specific gravity, not a lot of concentrated urine (HYPOatremia)

hypothyroidism

-congenital or acquired

-Hashimoto’s thyroidits: acquired 6+ months autoimmune

S/S: poor feeding, large fontanelles, bradycardia, puffy face, delayed puberty, constipation, impaired memory

-low T4 and T3, high TSH

-thyroid replacement therapy (levothyroxin; synthroid)

Graves Disease

autoimmune disorder caused by hyperthyroidism

S/S: goiter, raised thicken skin, increased sweating, tremors

thyroid storm: can be life threatening; normal after stressful event of illness, hypermetabolic state, N/V, tremors, psychosis

-high T3 and T4 and low TSH

tx: antithyroid drug (methimaazole)

-often first diagnoses as ADHD

hypoparathyroidism

-inadequate production of PTH

-inherited or aquired

S/S: poor teeth development, HA, seizures, spasms, HYPOcalcemia

-low calcium and mag (must be on tele and watch for cardiac arrythmias when giving IV calcium; seizure precautions), high phosphates

tx: supplemental calcium and vitamin D

Type 1 diabtes

• cell destruction resulting in definite insulin dependency

• polyuria, poludipsia, polyphagia, fatigue, N/V, yeast infections, dehydration, tachycardia, blurred vision

• random glucose over 200, HbA1c >7, two tests over 126, urine glucose and ketones increased

• S/S of hypoglycemia can be mistaken for a temper tantrum

• adolescents: struggle with peer and body acceptance, risk taking is common, will challenge authorty, smoking, alc, pregnancy, drug use, dietary splurges

• sick care and pubery changes

• if unconscious give glucagon

type 2 diabtes

caused by insulin resistance in which the body fails to recognize and use insulin properly

RF: obesity, sedentary lifestyle, high calorie/high fat diet

S/S: acanthosis nigricans (dark spots)

-education must include parents

-see provider every 3 months

Diabetic Ketoacidosis

S/S: kussmauls resp, thirsty, dehydrated, tachycardic, acidosis, high blood sugar over 240, polyuria, fruity breath

tx: hydrate, insulin, electrolyte replacement

-monitor blood glucose 3-6 times daly

immobilizing devices

splinting devices, boots, casts, skin tractions, skeletal tractions, distraction devices

-splinting devices and boots can be done in outpt or ER, easily removed

compartment syndrome

pressure w in closed fascial compartmens is raised when inflammation occurs in the tissue, decreased blood flow, and perfusion, blood flows distal to affected comparmtent cant stop

cast syndrome

compression of the SMA

neurovascular assessnemtn

-assess distal pulses

6 P’s: pain, pallor, pulselessness, polycythemia, paresthesia, paralysis

-apply ice and elevate extrememity (to prevent compartment syndrome)

-perform neuro assessments with vital signs (every 1-2 hrs first day)

-encourage holding (spica cast)

-prevent: cast syndrome: frequent repositoning, fluids and fiber, allow for “belly hole” for abdominal expansion

traction

-make sure traction weights are hanging free

-traction removed and reapplied every 4 hrs, skin care every 4 hrs

-diversionary activities/pain control

-hygeine and pin cleaning

-weight is based on doctors orders

congenital talipes equinovarus (clubfoot)

RF: amniocentesis before 20 wks, CVS (Chorionic villus sampling), obesity, smoking

S/S: plantar-flexed, inverted heel adducted forefoot, rigid and cannot be manipulated into a neutral position

tx: serial casts, 4-6 wks, adapt how much it realigns

Legg-calve Perthes disease

interrupted blood supply to the femoral head

S/S: pain that increased with activity, painful limp, quadriceps muslce atropy, joint dysfunction, limited ROM, hip or knee stiffness

tx: brace for 2-4 years or plaster cast for 1 year

-no weight bearing before the surgery

soft tissue injury

sprain: bone to ligament

strain: bone to tendon/muscle

tx: rest, ice, compression, elevate and early motion

fractures

-bone goes under more stress than it can absorb

causes: falls, MVAs, bikes

S/S: immovable limb, swelling around area, pain

-closed: no break in skin

-open: muscle, ligament and skin are affected

scoliosis

-nonpainful, lateral curvature of the spine

S/S; unequal shoulder height, chest symmetry, unequal leg length, rib prominences, scapular prominences and heights

diagnosis:

-adams postion “bend over”

10-15 degrees: mild checkup (Cobb angle)

15-40 degrees: back brace

40 more: surgery

-back brace worn 23 hrs a day

-spinal surgery necessary if pulmonary function is compromised

-turn Q2 hours (log roll), ambulate 5 days post op

Acne Vulgaris

-common BACTERAL skin disorders

-inflammatory and noninflammatory

-tx: accutane (two forms of bc; suicide)

Herpes Simplex Virus-1

“cold sore”

-enters the body and becomes latent

-triggers will cause flare ups

S/S; watery blisters around face. itchy, pain

-supportive care, oral antiviral (acyclovir) to reduce duration

Tinea’s Fungal infections

tx: antifungal topical

-promote dryness, wear loose clothes, put socks on before other clothes , 100% cotton socks

for capitis: oral antifungal Griseofulvin: give with fatty foods; help med cross BBB, takes hair 6-12 months for hair to grow back

oral candidiasis (thrush)

-can look like breastmilk on tounge

-RF: abx, prematurity, skin irritation, immunocompromised, steroids, newborn-mother w/ candidasis

tx: oral nystatin/clotrimazole applied to tongue and mouth

atopic dermatitis

“itch that scrathes”

-minimize itching

S/S: patches with papules, exudate, crusts, erythema, dry and cracked skin, darkening, thickening, lichenification

tx: skin hydration and lubrication (aquaphor, hydrocortisone cream, oatmeal baths, diluted bleach baths), maintain skin barrier (as soon as kid out of bath before skin drying)

-allergic (atopic) triad: asthma—> allergic rhinitis—> food allergies—> eczema (atopic dermatitis)

contact dermatitis

occurs after contact with allergens and skin irritants

-withing 48 hrs of contact

diaper management: avoid powder, wash with warm water, caution with baby wipes, expose skin to air when possible

emergency skin reaction

reversal of causative agent, decrease swelling with medications epinephrine, Benadryl, oxygen

dermatitis seborrheic

yeast overgrowth

-waxy scaling of scalp

-treat with emollient and use soft toothbrush (Not harmful, cosmetic)

scabies

highly contagious, caused by mites

-skin to skin; sexual

S/S: rash with papules and pustules, lesions that are linear and threadlike

tx: OTC lotion (elimite-permethrin 5%)

lice

highly contagious

-lay eggs at night. larvae hatch 7-10 days

-treat ALL family members, wash every in HOT water, not sharing, outside for 2 weeks if cant be washed

burns types

toddlers: exploration of environment( handles in)

1st degree: superficial thickness, damage to outer layer only

-redness and blanching with pressure

2nd degree: superfical partial thickness; epidermis and upper dermis (some sweat and oil glands may be damaged), heals 10-14 days, blisters, redness, blanches with pressure, pain (with cold air)

3rd degree: deep partial thickness, involves epidermis, dermis, and underlying tissue (nerve endings, sweat glands, and hair follicles)

-NON blanching, variety of colors

4th degree: full thickness (muslce, fascia, bone), non blanching, variety of colors, will not feel pain

burn management

initial phase:

-ABC’s first, stop the burn process

-moist socks, cool water, remove jewelry and clothing, do not disturb blisters

-begin fluids resuscitation IMMEDIATELY to restore circulation volume and optimize perfusion and minimize burn shock

-heat lose is rapid through skin, fever is expected

-aggressive pain management

pituitary hypofunction

measure height and weight on growth chart

-causes growth hormone deficiency

-delayed growth of less than 2 inches a year needs to be evaluated

-delayed puberty, including a high pitched voice, small penis and testes in boys

pituitary hyperfunction

precocious puberty

-secondary sex characteristics developing before age 8 in girl and age 9 in boys

normal: girls 8-13, boys 9-14