Pediatrics Exam 3

Life threatening GI symptoms/conditions?

Red flags for serious causes?

dehydration, infection, IBD, celiac

poor appetite, weight loss, poor growth, blood/mucous in stool, nocturnal symptoms, pain awakens from sleep

Most common abdominal pain in 6 y.o?

Constipation

Most common abdominal pain cause in 16 y.o?

functional abdominal pain (FAP)

**also think about pregnancy

what do you think about with vomitting in 2 m.o?

Pyloric stenosis

Pyloric stenosis: presentation/sx/exam/treatment

• 3-12 weeks old

• non bilious projectile vomiting after feeds

• hungry feeder

• PE: olive shapped nontender mobile mass to R of epigastrium

• US shows elongated and thick pylorus, upper GI shows string sign

• Tx: surgical pyloromytomy

Functional constipation: presentation/sx/exam/treatment

• most common cause of abdominal pain in kids

• encopresisEncopresis: passage of stool into underwear under 4 y.o

• Tx:

  • disimpaction/clean out (stimulant laxatives)

  • maintenacne: 3-6 m stool softener, lube, laxative, behavior, diet

  • weaning meds slow and continue good habits

Celiac Dz: presentation/sx/exam/treatment

• sx: diarreah, stearrhea, Fe deficiency

• autoimmune, fam hx

• PE: short, abd distention, mouth ulcers

• Dx: TTG IgA, upper endoscopy with SM biopsy

• Tx: gluten-free diet

IBD: presentation/sx/exam/treatment

• adolescent; sx: crampy abdominal pain, bloody diarrhea, extraintestinal manifestations

• PE: possible perianal abscess/fistula

• Dx: positive labs, upper and lower endoscopy w/ biopsy

• Tx:

  • induction to induce remission Ex: exclusive enteral nutrition therapy

  • Maintenance to prevent inflammation and flares

  • possible colectomy for UC

Functional abdominal pain: presentation/sx/exam/treatment

• most common cause of abdominal pain in adolescents

• disorder of gut-brain interaction

• Sx: altered bowl habits, abdominal pain relieved with defacation.

• Dx: Rome IV criteria. NO + LAB RESULTS

• Tx: stress management, psychosocial support, low FODMAP diet, supplements, meds for sx

mild, moderate, severe dehydration presentation and tx

• normal PE, active alert, normal vitals, moist mucous membranes: oral rehydration (small sips/4 hrs)

• irritable, alert, thirsty, dry mucus membranes: oral rehydration

• lethagic, sick, vitals unstable, sunken frontanelle, severely reduced UO: IV fluids (isotonic saline/formula)

**Consider antiemetics (ondansetron) for nausea

GER vs GERD presentation and tx

GER

• “happy spitter”

• normal in 50% of infants less than 3 mo. peaks at 4m resolved at 12-24 m

• Tx: sit upright 20-30 min after feed. smaller, more frequent feeds, avoid overfeed

GERD

• irritability, poor feed, poor weight gain

• Tx: protein-free milk, UGI imaging to r/o malrotation, 2 wk trial of H2 blocker (famotidine), peds GI

Migraines: presentation, treatment

• 4-72 hr unilateral/pulsating pain aggravated by activity. Looks sick, improves with sleep

• N/V/photophobia

• Fam Hx important!!!

• association with mental and behavioral health conditions

• Tx: CBT, encourage school attendance

  • #1: Ibuprofen

  • amitriptyline, topiramate, propranolol, triptans

Tension type HA: presentation, treatment

• bilateral pressing/tight “band around head”

• NOT aggravated by physical activity

• association with mental and behavioral health conditions

• Tx: CBT, encourage school attendance

  • #1: Ibuprofen

  • amitriptyline, topiramate, propranolol, triptans

Post concussive HA

• Fatigue is most common followed by HA

• increase risk for depression and anxiety

What is epilepsy? Risk factors? Treatment?

• 2 unprovoked seizures, 1 unprovoked seizure with 2+ risk factors

• Age <1 yr, abnormal PE, development, EEG, MRI and Fam Hx

• Tx:

  • Generalized: Keppra (levetiracetam)

  • Focal: carbamazepine, oxcarbazepine

  • status epilepticus: midazolam

Infantile spasms (west syndrome): presentation, treatment

• 4-8 m

• trunk and arm spasms. can lead to developmental regression and risks long term deficits

• Tx: high dose steroids, vigabatrin

Lennox-Gastaut syndrome: presentation, treatment

• infancy/toddler

• mixed seizures that evolve and cause cognitive delay and are often refractory

• tx: aggressive meds, diet, surgery, CBD

Benign focal epilepsy (BECTS, Rolandic Epilepsy): presentation, treatment

• grade school (8-9 grade)

• nocturnal unilateral facial parenthesis spread to ipsilateral arm and leg

• usually outgrow

Absence Epilepsy: presentation, treatment

• brief staring spells

• childhood (5-7 yr): outgrow

• juvenile (>10 yr): overlaps with juvenile myoclonic epilepsy TREAT!

Juvenile myoclonic epilepsy: presentation, treatment

• most common cause of new onset GTC seizures in teens

• Triggers: sleep deprivation, EtoH, menses, flashing lights, hereditary

• often dont remit

Reflex epilepsy: presentation, treatment

• triggered by stimulus: flashing lights, reading, music, video games

panayiotopoulos syndrome

• 4-5 yrs

• occipital epilepsy

• non-convulsive ictal sx: N/V, CV and thermal dysregulation

• does NOT impact development

Febrile seizures: age, workup? management

• 6m-6y

• only work up if complex: EEG, neuroimaging, referral to peds

• support and monitor

Metatarsus adductus: presentation, management

• “packaging issue”

• metatarsals leaning medially

• PE: heel bisector line

• often self correcting (flexible), but refer to ortho if rigid

congenital talipes equinovarus (clubfoot): presentation, management

• CAVE (midfoot spin): Cavus/high arch, Adductus Varus/heel curl, Equinus/foot points downward

• refer to ortho: serial casting (ponseti method), tenotomy, boots and bars. surgery is NOT first line due to development of OA

tibial torsion (shin bone twist): presentation, management

• presents with in-toeing/out-toeing

• brace,PT, orthotics DO NOT WORK

• refer to surg if 10 yo and still tripping

Os Good Shlatter: presentation, management

• painful tibial tubercle in adolescent and resolves after growth

• Tx: streatching/quad flexibility, NSAIDS, ice, patellar tendon strap

• can continue to play spots

Patellofemoral syndrome : presentation, management

• vague diffuse pain and timing, C sign. Cant localize with one finger

Developmental dysplasia of hip: sx, tx

• instability/loosness of hip joint.

• Risk factors: Female, first born, fam hx, frank breech

• sx: +ortolani'/barlow, hip click/clink when diapering, leg length discrepancies, limited hip motion, gait abnormalities

• Tx: pavlik harness <6m spica cast >6m surgery if late presentation

leg calve perthes: sx, tx

• idiopathic avascular necrosis of femoral head, progressive

• Boys 4-7 yo with painless limp

• hip/knee pain worse with activites

• semiurgent referrel

Slipped capital femoral epiphysis (SCFE): sx, tx

• displacement of femoral head through growth plate “ice cream fallen off the cone”

• painful limp, often knee pain

• during adolscence, male, obese

• surgical emergency: scew to stop progression

Scoliosis Who? screen?

• F 10-22 y, M 13 yr

• adams forward bending test, Cobb angle scoliosis vie x ray

Nursemaids elblow

• pull injury

• annular ligament subluxation,

• Tx: reduce

Croup: caused by? sx, presentation, dx, tx

• 6m-3y

• acute laryngotracheitis (upper airway inflammation)

• parainfluenza virus

• barking cough, stridor, worse at night, steeple sign on xray

• Tx: dexamethasone, neb epi, cool air

Acute bronchitis: sx, presentation, dx, tx

• inflammation of large airways, viral cause

• acute cough, normal exam (r/o other things)

• Tx: supportive (expect lingering cough)

Bronchiolitis: caused by? sx, presentation, dx, tx

• infection of small airways. 3-6m.o

• RSV

• increased respiratory effort

• Tx: supportive, hydration, resp support, suction, antipyretics, monitor status (admit if low O2)

Community acquired pneumonia: sx, presentation, dx, tx

• leading cause of death in kids under 5

• strep pneumo

• fever, cough

• Tx: amoxy, azithro if atypical, vaccine, f/u in 2-3 d to ensure improvement

Urinary incontinence over 5 yo management

1. behavioral

2. enuresis alarm

3. desmopressin (DDAVP)

contraindications to circumcision? Advantages?

• hypospadias, buried penis, hydroceles

• reduced risk of cancer, STI, and UTIs (treat with cephalexin, Augmentin, TMP/SMX)

Varicella: sx, presentation, tx

• “dew drops on a rose petal”

• 1-2 day flu prodrome→rash→resolves in 7-10d

• vescicles on erythematous base face to extremeties. in different stages

• Tx: acycolvir, anti inflammatory, antihistimines, calamine

Meales: caused by? sx, presentation, tx

• paramyxovirus

• COUGH, CORYZA, CONJUNCTIVITIS

• URI prodrome, high fever, koplik spots then rash

• maculopapular morbilliform brick red rash. resolves in 7-10d

• supportive care

Erythema infectiosum (5th dz): caused by? sx, presentation, tx

• Parvovirus

• “slapped cheek appearance”

• nonspecific prodrome, fever→rash 1-3 weeks to resolve

• red flushed face with circumoral pallor→lacy reticular rash on body

• Supportive care

Roseola infantum: caused by? sx, presentation, tx

• HHV6-7

• 3 days high fever→rash when fever stops

• pink maculopapular blancable rash starts on trunk/extremeties→face

• Supportive care

Hand, foot, mouth: caused by? sx, presentation, tx

• coxsackie

• fever and URI prodrome

• painful vesicular lesions on reddened base with erythmatous halo in oral cavity→lesions on hands, face, feet, genitals, including palms and soles

• supportive care

Diaper dermatitis: what is it? what causes it? presentation? complication? management?

• Irritant contact dermatitis occurs on convex surfaces in contact with the diaper. spare skin folds

• caused by moisture, friction, fecal enzymatic activity

• mild asymptomatic papule to severe extensive erythema, erosions, nodules

• could lead to candida if not treated

• Management:

  • frequent change, air, clean, powder

  • barrier ointment for mild to moderate

  • 1% hydrocortisone for severe

  • candida (beefy red plaques w/ satellite papules involving skin folds): clotrimazole

Neuroblastoma: age, presentation, dx,

• 0-2 y

• abnormal neural crest cells from adrenal medulla and sympathetic ganglia

• const sx, blueberry muffin rash, horner syndrome, racoon eyes

• Dx: urine metabolites MRI, biopsy

acute lymphoblastic leukemia (ALL): age, presentation, dx, tx

• 2-5 yo

• pancytopenia, fever, bruise, pallor, hepatosplenomegaly, lymphadenopathy

• dx: bone marrow biopsy

• tx: chemo

osteosarcoma: age, presentation, dx, tx

• adolescent

• metaphysis of long bone (distal femur)

• sx:localized bone pain, worse at night, joint swell

• sunburn appearence on x ray

• Dx: biopsy

• Tx: chemo→surg→chemo

Ewing sarcoma: age, presentation, dx, tx

• adolscent

• diaphysis of long bone (proximal femur)

• bone pain, swell, systmic sx

• onion peel appearence on x ray

• Tx: chemo→surg if possible

Hodgekins lymphoma: age, presentation, dx, tx

• asymptomatic painless lymphadenopathy, mediastinal mass, B symptoms

• Reed-Sternberg “own eye” cells

• dx: lympth node biopsy

• Tx: chemo

long term sequelae of childhood cancer?

• neurologic

• cardiac

• endocrine: imparied growth, obesity, thyroid dys, fertility issues

• secondary malignancies

cystic fibrosis: patho, manifestations, dx, management

• autosomal recessive in CFTR gene leads to abnormal Cl and H2O transport across exocrine glands, causing thick, viscous secretions

• GI: pancreatic insufficiency, steatorrhea, rectal prolapse, prolonged jaundice of infancy,

• Reproductive: sterility (m), congenitcal absence of vas deferens, decrease f fertility with thicker cervial mucus

• Increased salt in sweat

• Resp: bronchiectasis, recurrent pulm infx, sinisitus, nasal polyps

• Dx: elevated sweat Cl test

• Management: high fat diet, with fat soluble vitamins (ADEK), pancreatic enzyme replacement, airway clearance, inhaled meds, systemic antibiotics for pneumonia, (CFTR protien modulators)

Childhood poverty knock it off. How to mitigate?

• 21% of kids live below the poverty line

• Medicaid, free clinics, supplemental nutrition assistance program, section 8 vouchers for housing, earned income tax credit, paid fam leave

limitations of the federal poverty level?

• outdated! does not account for the regional cost of living diff, changes in food, other resources