CMS 3 review

1. PEDS

1. PEDS

What is the Fetal Biophysical profile?

*Note Evaluated using US

1. Movement

2. Tone

3. Amniotic fluid volume

4. Breathing (movement)

Pre-term vs. Term. vs. Post-term

Pre-term = < 37 weeks

Term = 37 - 42 weeks

Post-term = > 42 weeks

Birth weight doubles by ____?

Birth weight triples by _____?

Patient is 7lbs how much will they weigh in 6 months and twelve months?

Double → 4-5

Triples → 1 year

6 months = 14 lbs

12 months = 21 lbs

Low Birth Weight

Not gestational age dependent

-Low: <2500g

-Very Low: <1500g

-Extremely low: <1000g

Twin-twin transfusion syndrome

One fetus receives too much blood and the other receives too little

Monochorionic twins; unbalanced Blood Flow

HypERvolemic & hypOvolemic

Comp: CHF, fetal hydrops

Dx: US early 2nd tri

Fetal Circulation

Ductus Venosus = oxygenated blood

Umbilical Arteries = Deoxygenated blood

APGAR

Appearance: Pink | Extremities Blue (acrocyanosis) | Pale or Blue

Pulse: >100 | < 100 | no pulse

Grimace: cries and pulls away (coughs or sneezes) | grimaces or weak cry | No response

Activity: Active movement | arms, legs flexed | no movement

Respiration: Strong cry | slow, irregular No breathing

Test run at 1 & 5 +/- 10 min ---- Top score = 10

< 4 @ 1 min → resuscitate

< 7 at 5 min → CNS / CV risks 🧠♥️

Familial Hypercholesterolemia

Autosomal dominant

Child will have elevated LDL and high BMI

You see air bronchograms, ground glass on CXR in a child what should you be thinking and what is the cause?

Sx: tachypnea, grunting, cyanosis, nasal flaring

Hyaline Membrane Disease (RDS)

Cause: SURFACTANT DEFICIENCY - premie!

Tx: surfactant replacement (30-60 min birth)

Prevent: Antenatal steroids (24-34 wks) 🫁

What is the MCC of respiratory distress (RDS) in term infants?

Transient Tachypnea of Newborn

Cause: fetal lung fluid is retained

CXR: increased lung volumes w/ flat diaphragm (no bronchogram or ground glass)

XR/KUB (Kidney, Urea, Bladder) shows Pneumatosis Intestinalis

Necrotizing Enterocolitis

Inflammatory bowel w/ hypoxic injury - premie!

Necrosis of intestinal mucosa / gas bacteria

Sx: flatulence, ileus (vomiting), hematochezia, abd distention / tenderness

Treatment: NPO, NG decompression, abx

Developmental Milestones

- 2-3 mo: 180 visual tracking, lifts head 45

Coos

- 4 mo: no head lag, rolls PRONE to SUPINE

Laughs

- 6 mo: rolls SUPINE to PRONE, sits WITH support

Babbles

- 9 mo: sits with SITS NO SUPPORT - Mama, dada, responds to name

- 12 mo: mama & dada (specific), 1+ word

- 15 mo: crawls stairs (walks well)

- 18 mo: runs kinda, 2 feet per step up stairs w help-- Takes off gloves, shoes, socks--Scribbles

- 24 mo: runs well, 2 feet per step up stairs ALONE

Some clothes; vertical / circular strokes-- 2 word sentences, follows 2 step commands - AT 2

- *3 yrs: tippy toes, alternating stairs, hops 2-3 x*--Dresses with supervision-- Copies circle ⭕

- 4 yrs: tandem walks, hops 5 times-- Dresses without supervision-- Copies cross ✝️-- 100% intelligible to a stranger

Motor Reflexes

Stepping: air walking → Birth to 1-2 mo

Rooting: tryna suck → Birth to 3 mo

Moro/startle: arms out uh-oh → Birth to 3-6 mo

Grasping: gimmie gimme

→Palmar: birth to 3 mo

→Plantar: birth to 9-12 mo

→Brings to mouth: 4 mo

→Hand to hand / raking grasp: 6 mo

→Pincer grasp: 9 mo **

→MATURE pincer: 12 mo

Galant: tickle reaction →Birth to 3-6 mo

Fencer (tonic neck): 1 up & 1 down → Birth to 4-6 mo → Asymmetric tonic neck

Babinski: foot stroke (up going until 12 months)→ Birth to 9-10 mo

PERSIST THROUGHOUT LIFE

→ Parachute (ext)

→ Head righting (tilt body)

→ Protective equilibrium (flex trunk)

Tanner stages

1. Childhood

2. Pubic hair appears (adrenarche); breasts buds

3. Pubic hair darkens and becomes curly; penis size/length increase

4. Penis width increase, darker scrotal skin, development of glans, raised areolae

5. Adult; areolae are no longer raised

Salter Harris

I - fx across growth plate

II - fx across growth plate + metaphysis

III - fx across growth plate + epiphysis

IV - fx across growth plate + metaphysis + epiphysis

V - growth plate crushed

What should you be thinking if you hear bowel sounds in thorax of newborn?

Congenital Diaphragmatic Hernia

Erb Duchenne Palsys

Waiter tip sign → C5-C7

MCC shoulder dystocia

When does a baby sit with support?

6 months

No support at 9 months

What is superficial edema/ ecchymosis that crosses the suture line?

Caput succedaneum 🧢

Cephalohematoma: blood collection under periosteum (does NOT cross suture line)

Subgaleal hemorrhage: btw scalp + skull→blood goes to dependent side

What causes a loss of the red light reflex?

Retinoblastoma

Hip Dysplasia (Mechanical instability of the hip)

RF: Breech position, FHx, females

Barlow (Dislocates) = Barlow = Bad

Ortolani (Relocation) = Dr. O = Good

What are white papules keratine and sebaceous material in philosebaceous follicle? (Nose and cheeks)

Milia

Autism screening

M-CHAT Questionnaire (18mos)

Impaired social skills but no language impairment

Asperger's

Intellectual disability, Heart defects (ASD), single palmar crease, macroglossia

Down Syndrome (Trisomy 21)

MC sex abnormality in females

Turner syndrome → short, wide nipples, horseshoe kidney, primary hypogonadism

Diagnose based on:

MALES

Sx: tall/slim, LONG extremities, feminizing features, micropenis, hypospadias, small testes, gynecomastia

Klinefelter Syndrome

Diagnose based on:

Mutation in fibrillin 1 (FBN 1)

Sx: aortic dissection / aneurysm, bluish sclera, MVP, joint hypermobility

Marfan's Syndrome

Diagnose based on:

Paternal deletion of 15q11

Sx: OBESE, speech delay, OSA, short, hypogonadism, cryptorchidism, almond-shaped palpebral fissures, fish-like mouth

Infancy = poor weight gain

Early Childhood = obesity

Prader Willi Syndrome

What happens with Maternal Lithium Ingestion?

Ebstein's Anomaly

Cyanotic Heart Diseases

Tetralogy of Fallot

Transposition of the great arteries (TOGA)

Hypoplastic Left Heart (HLH)

Tricuspid atresia

Ebstein's Anomaly

Total anomalous pulmonary venous connection

Truncus Arteriosus

Acyanotic Heart Diseases

Ventricular Septal Defect (VSD)

Atrial Septal Defect (ASD)

AV Canal Defect

Pulmonary Stenosis

Patent Ductus Arteriosus (PDA)

Aortic Stenosis

Coarctation of Aorta

S&S of Tetralogy of Fallot?

"PROV"

-Pulmonic Stenosis

-RVH

-Override Aorta across VSD

-VSU

CXR: Boot shaped heart - RVH

Decreased pulm vascularture markings

Kawasaki Disease

"FEARS ME"

- Fever

- Eyes (Bulbar conjunctivitis)

- Arthralgia/Arthritis

- Rash

- Skin (desquamation in hands/feet)

-Mucosal Involvement (strawberry tongue)

- Elevated ESR/Platelets

Complication: coronary a. aneurysm or thrombosis

ADHD

MC neurobehavioral disorder of childhood

Inattentive / Impulsive w/ hyperactive / Combo

Questionnaire: Conners or Vanderbuilt

Tx: Stimulant - Ritalin

Stimulants

Ritalin → insomnia / ↓ appetite

Concerta ER → do homework QHS

Non-Stimulants

Strattera → less appetite suppression

Guanfacine (Intuniv) ** → less appetite suppression

Diagnose based on:

Total Bilirubin >18 mg/dL

S&S: Lethargy, V, irritable, poor feeding, high pitched cry, damage to basal ganglia

Kernicterus

How do you prevent Sudden Unexpected Infant Death (SUID)?

no bumpers, toys, pillows in crib

Sleep SUPINE

If you see an olive shaped mass, what should you be thinking?

Sx: non bilious emesis, persistent hunger, “olive-shaped” mass

Labs: hypokalemia, hypochloremic metabolic alkalosis

XR → gastric distention

US → confirms

Pyloric Stenosis

Tx: IVF; definitive tx → pyloromyotomy

Language in Kiddos

-- ALWAYS SCREEN HEARING

-- Do NOT delay screening d/t bilingual or not being 1st born **

Stuttering: normal from 2.5 - 5 yo

Evaluation IF Stuttering:

----Onset > 5 yo **

----Persists > 6 mo **

----Child distressed

----Parent concerned

----(+) FMHx

fever in baby

100.4

If you see retinal hemorrhages, subdural hematoma, what should you think?

shaken baby

Diagnose based on:

MC organisms: pseudo, strep, and staph

Sx: discharge, pinna/ tragus pain

Acute Otitis Externa: “swimmer’s ear”

Tx: >6 mo (ciprodex), > 2 yo (cortisporin)

You betta not give antibiotics!

Diagnose based on:

TYPICALLY FOLLOWING A URI!!

Organisms: S. pneumo, H. influ, M. cat

PE: RED, bulging TM, air-fluid level behind TM, ↓ TM mobility, ↓ hearing

Acute Otitis Media

Tx: Amoxicillin, Augmentin

PCN allergy: macrolide, ceph?

Refer: >3 AOM in < 6 mo, > 4 in 12 mo

Consider tubes if > 4 OM in one year

Complications: TM perforations, hearing loss (conductive), mastoiditis

Causes of conductive hearing loss

Acquired:

Middle ear effusion

FB

TM perforation

cholesteatoma

Congenital:

Craniofacial abnormalities

microtia/atresia

Abnormal TM/Ossicles

Diagnose based on:

Sx: barky “seal” cough, inspiratory stridor

Dx: lateral neck XR → narrowing from edema (Steeple sign) + normal epiglottis

Laryngotracheobronchitis (Croup) → parainfluenza virus type 1 and 2

Tx: ADMIT

Mild: humidification in home setting

Steroids: Dexamethasone

Mod-sev: racemic epi (GS)

Diagnose based on:

Inf of the mastoid air cells → rare comp of AOM

MC - S. pneumo, S. pyogenes, S. aureus

Recurrent OM or recent Tx’d - pseudomonas

Sx: swelling, red / tender mastoid, pinna displaced

Dx: CT (most reliable)

Mastoiditis → Dx CT (most reliable)

Treatment:

w/o recurrent AOM / recent abx → Unasyn

w/ recurrent AOM / recent abx → Zosyn

PCN allergy → vanco or linezolid + flagyl

What presents with B/L pruritis, diffuse conjunctival erythema, and conjunctival chemosis?

Allergic conjunctivitis

What is bluish opalescent sheen on teeth?

Dentinogenesis imperfecta → d/t genetically defective dentin

***associated with osteogenesis imperfecta

Any child with nasal polyps should be evaluated for what?

Cystic fibrosis and Asthma

Diagnose based on:

Cause: viral URI/allergic rhinitis

Sx: prolonged URI (> 7-10 days + halitosis), purulent rhinorrhea, sinus tenderness, HA

Dx: complicated → CT

---Caldwell → ethmoid sinuses

---Waters → maxillary sinuses

Sinusitis → Augmentin

Peritonsillar Abscess Etiology

Sx: hot potato voice, UL sore throat, drooling, dysphagia, torticollis

Group A strep, S. aureus

Tx: drain + augmentin or clindamycin, ENT referral

Pt had fever, red, swollen tonsils, ant adenopathy, and is allergic to PCN... diagnosis and treatment?

Acute Tonsillopharyngitis GABHS

Treatment: Azithromyacin

Diagnose based on:

Sx: fever, stridor, drooling, respiratory distress, sniffing or tripod posture

Dx: lateral neck XR ”thumb sign”

Epiglottitis → H.influ

Tx: INTUBATE, IV abx (ceft + vanco)

Impetigo

MCC = S. Aureus / GABHS → Mupirocin

Diagnose based on:

Sx: sandpaper rash + strawberry tongue w/ circumoral pallor

Scarlet Fever → GAS (Strep pyogenes)

Tx: 1st line → PCN V

Know the tx for kidney stones based on size

<4 mm = fluids, pain relief, manage

>4mm = surgery, lithotripsy

When should pt receive orchiopexy by?

Before 1y/o

Absence seizure presentation on EEG

3 Hz spike & wave

Tx: Ethosuximide

VACCINATIONS

DTap & DT (< 7 yo)

2 mo, 4 mo, 6 mo, 15-18 mo, 4-6 yrs

Tdap & Td (> 7 yo)

11-12 yo (if > 5 yrs since DTap)

Repeat every 10 yrs

MMR (same schedule as Varicella)

12 mo-15 mo & 4-6 yo

Prior to 12 mo → INVALID

Hib → DO NOT GIVE < 6 WEEKS OLD

Meningococcal

16-23 yo; 2 doses

Influenza

All children > 6 mo

First shot? NEED A BOOSTER

CI: EGG ALLERGY

HPV (Gardasil 9)

1st dose < 15 yo → 2 dose series

0 mo & 6-12 mo apart

1st dose > 15 yo → 3 dose series

0 mo, 2 mo & 6 mo apart

ANTIDOTES

Live Vaccines

“MOVe You Red Neck SOB!”

MMR

OPV → polio

Varicella

Yellow fever

Rotavirus (oral)

Nasal flu (flumist)

Smallpox

Oral Typhoid

BCG

If not given on the same day → wait 28 days b/w live vaccines

ALL

lymphoblasts >20%

Schistocytes on blood smear, ↑ (retic,

LDH), normal PT/PTT/fibrinogen

Thrombotic Thrombocytopenic Purpura

Tx: large volume plasmapheresis

↓ plt count, blood smear → megathrombocytes

Immune Thrombocytopenic Purpura (ITP)

Diagnose based on:

Sx: hemarthrosis, hematomas

Dx: normal PT & plts, prolonged aPTT, ↓

activity of factor VII

Hemophilia A: factor VIII def

Diagnose based on:

Deficiency/dysfunction of protein (vWF):

Types: I (deficiency), II (defective), III (absence)

Sx: mucosal bleeding, menorrhagia

(microcytic anemia), hemarthrosis → type II

Dx: prolonged → bleeding time, PTT → d/t ↓

factor VIII

Von Willebrand Disease: MC inherited → DDAVP

Schilling test

Vit B12

Fever Treatment

S: 100.4 (38C) RECTAL IS BEST

Neonates: MC → group B strep → Ampicillin & ceftriaxone

Infants (29-60 days): GBS, E.coli, S. pneumo,

H. influ, S. aureus, N. idis

→ Cefotaxime/ceftriaxone → Ampicillin → E.coli, listeria, or suspected meningitis

→ Vanco → MRSA

Infants (61-90 days): S. pneumo, H. influ, N.

meningitidis, E. coli (UTI)

→ Cefotaxime/ceftriaxone + vanco (if

indicated)

ADMIT ALL FEBRILE!!

Alkaline toxicity (drain solution ingested and what do you do)

Intubate

Nephrology

Nephrology

What is the most important function of the glomerulus?

Filtration

Where in the Nephron does Acetazolamide work?

Proximal Convoluted Yubule

Where in the Nephron does Mannitol (Osmotic diuretics) work?

Descending limb

Where in the Nephron does Furosemide work?

Loop of Henle

Where in the Nephron does HCTZ work?

Distal Convoluted Tubule

Where in the Nephron does Spironolactone?

Collecting Duct

What are the 5 stages of Chronic Kidney Disease (CKD)

1: > 90 (damage, proteinuria, normal GFR)

2: 60 - 89 (damage, mild decrease in GFR)

3: 30 - 59 (moderate decrease in GFR) ref Nephrologist

4: 15 - 29 (severe decline in GFR)

5: < 15 (kidney failure)

When doing a UA in a very muscular patient what should be used to monitor their creatinine levels?

Cystatin C

Osmolality Gap Equation?

2x serum Na + (BUN/2.8) + (Glucose/18)

> 15 critical → indicates exo mannitol & ethylene glycol

↓ blood pH, ↑ anion gap & ↑↑ OG → med EMERGENCY

HAGMA

"MUDPILES"

Methanol

Uremia

Diabetic ketoacidosis

Propylene glycol

Isoniazid, Iron

Lactic acidosis

Ethylene glycol

Salicylates

NAGMA

"HARDUP"

Hyperalimentation

Acetazolamide

RTA (renal failure)

Diarrhea

Ureteroenteric fistula

Pancreatic fistual

What saline should you give to patients with symptomatic hyponatremia?

Hypertonic 3% Saline

WATCH FOR Central Pontine Myelinolysis

DON'T USE → HEART/RENAL FAILURE, or conditions d/t cellular dehydration

What saline should you give to patients with hypernatremia w/ ECFV depletion?

Hypotonic 0.45%

Salicylate (ASA) poisoning

Metabolic acidosis, Respiratory alkalosis

Winters Formula

PCO2 = (1.5 x HCO3) + 8 +/- 2

If value falls within the range → compensatory; falls outside of the range → separate imbalance

RAAS

Angiotensinogen → RENIN → Angiotensin → ACE → Angiotensin 2

What are the indications to start a patient on dialysis (RRT (HemoDialysis))?

Initiate : Stage V or serum Cr or 8 mg/dL

Diabetics: start when serum Cr is 6 mg/dL

What is the MC childhood abdominal malignancy?

RF: Cryptorchidism, Horseshoe kidney, Hypospadias

PE: abd mass, UTI, HTN

Wilms Tumor (Nephroblastoma):

What is the MCC of renal failure d/t renal hypoperfusion?

Cause: CHF

Labs:BUN/Cr > 20:1 ratio; UNa < 20; FENa < 1;hyaline casts

Prerenal azotemia

What is secreted in the Cortical Collecting Duct?

H+

What is reabsorbed in the proximal convoluted tubule?

HCO3 and Glucose

Diagnose based on:

Heavy proteinuria > 3.5 g/day

Hypoalbuminemia (<3)

Edema (hallmark)

Nephrotic Syndrome

Diagnose based on:

Hematuria

HTN

Edema

Mild proteinuria

Decreased GFR

Coca cola urine

Nephritic syndrome

MCC Nephrotic Syndrome in kids

Minimal Change Disease → Diagnostic response to prednisone (disappearance of protinuria)

MCC Nephrotic Syndrome in adults

Membranous nephropathy→ inc. renal vein thromnosis, occult neoplasms

What is a nephrotic syndrome, secondary to heroin abuse, common in HIV?

Focal Segmental Glomerular Sclerosis

1st indicator of renal disease

proteinuria

What will be seen on labs in Post Infectious Glomerular Nephritis?

RBC Casts

Proteinuria < 3.5 g/day

Increased ASO

+ Strep Test (Or recent strep)

Coca cola urine

What is the hallmark of Glomerulonephritis?

RBC casts