pediatrics 3

an infant/ new born presents with fever lethargy vomiting and poor feeding for the last two days whats the first suspected Dx? what Invx we carry ?

-UTI

-older can void on request MSU precontinant unable to void on request younger clean catch infant SPA (before AB) (10’5ml /10’8l/any growth)

whats the treatment for UTI

oral trimethroprim/ cefalexin

IV gentamicin + benzylpenicillin (less than 3m/seriously unwell)

when is renal u/s carried in UTI

urgent/prior to discharge > 1)unwell 2)<3m boy 3)renal impairment

non urgent> 1)recurrent 2)<3yrs

A 2-24months old baby comes to your clinic with recurrent episodes of fever lethargy and poor feeding he was previously diagnosed with UTI wht is the most suspected Dx ? What imagining studies do we do ? Whts the rx?

Dx: VUR

Imaging studies: U/S (obs/hydro/scarring/3-4 grade) > VCUG

Rx: treat uti recurrent 3-4:surgery

A 2-24months old baby comes to your clinic with recurrent episodes of fever lethargy and poor feeding he was previously diagnosed with UTI wht is the most suspected Dx ? What imagining studies do we do ? Whts the rx?

Dx: VUR

Imaging studies: U/S (obs/hydro/scarring/3-4 grade) > VCUG

Rx: treat uti recurrent 3-4:surgery

what are the enuresis red flags for which we do dipstick urine analysis

1) acute onset

2) voiding symptoms (dysuria, polyuria, polydipsia, distended bladder)

3) Fhx if kidney disease

4) hypertension

A 5 years old child presents with bed wetting that is more markable at night the mother says it’s been going since he was young there are no other symptoms and physical examination was remarkable physical examination whats the managment?

Reassurance day time normal by 4 yrs night time bed wetting is normal 5-7yrs

A 10 years old child presents with bed wetting that is more markable at night the mother says he was potty trained and this started happening 3 weeks ago whats the managment?

Invx: urine dipstick

Rx: pad and bell alarm

Desmopressin sl or oral (if pad and bell doesn’t work)

Most initial and successful way to treat bed wetting ? Disadvantages

Pad and bell alarm

Takes 6-8 wks to work

A 10 years old child presents with bed wetting that is more markable at night the mother says he was potty trained and thus happened recently he is going to camp in 1 weeks time whats the proper management?

Desmopressin sl or oral

Limit fluid intake 1 hr before dose and 8 hrs after dose

Most common pediatric surgical condition

Inguinal hernia

Second most common pediatric surgical condition

UDT

UDT vs ectopic testis

Testis that is not in the scrotum but along the processus vaginalis vs testis not in the scrotum or the processus vaginalis

ascending testis vs retractile testis

Previously descended but ascended (remnant of PV) vs can be brought all the way into the scrotum but retracts (cremasteric muscle contracts after androgen levels drop after 3-6 m)

When is the cremasteric muscle most relaxed

Birth

3-6m

Rx for unilateral UDT palpable

Surgical referral 3-6m

Orchidopexy 6-12m

Rx for unilateral impalpable UDT

Surgical referral 3-6m

Diagnostic laproscopic exam 6-12m

Rx for bilateral palpable UDT without any sexual ambiguity

Surgical referral 3-6m

Orchiedopexy 6-12m

Rx for bilateral impalpable UDT with or without sexual ambiguity

Urgent surgical referral

Sexual disorder differentiation investigation

Diagnostic Laparoscopic examination

Wilms vs neuroblastoma age group? Syndromes associated with? C/f? Dx

1)2-5yrs vs <2yrs

2)WAGR,beckwith-Wiedemann syndrome, hemihypertrophy/macroglossia/visceromegaly vs NF, hirschprung disease , N-myc oncogene

3)Asymptomatic vs symptomatic (fever/FTT)

non tender abdominal mass doesn’t cross midline vs non tender abdominal mass that crosses the midline

4) FNA vs FNA

5)CT claw sign vs calcification inside the tumor

A child between 6m - 6y presents with a hx of seizure 3 days ago his mother says he has no hx of neurological abnormalities/infections or any metabolic disturbances on his examination the child is fatigued feverish well oriented on the video the mother showed of the seizure it lasted <15 min , with generalized involvement Whts the Dx? Invx ? Rx?

A simple febrile seizure

Nothing

Treat underlying infection seizure > midazolam/diazepam

A child between 6m - 6y presents with a hx of seizure 3 days ago and another one 2 days ago his mother says he has no hx of neurological abnormalities/infections or any metabolic disturbances on his examination the child is fatigued feverish dis oriented on the video the mother showed of the seizure it lasted >15 min , with focal involvement Whts the Dx? Rx?

Complex febrile seizure

Refer to local pediatric team

When do we consider referring a child with febrile seizure to a local pediatric team ?

1) seizure cant be controlled

2) complex febrile seizures (focal, >15 min, incomplete recovery after 1 hr, multiple within 24hrs)

3)clinically unwell (?)

A 3m- 7m old child presents with sudden brief clusters of bilateral symmetric contractions of neck , trunk and extremities (extensor and flexor) mostly shortly after waking up whats the Dx? Invx?rx?

Dx: Infantile spasms

Invx: Urgent neurological consult , sleep and wake EEG, mri

Rx: 1St line perdnisolone 10 mg 2wks

2nd line vegabitrine (if prednisone upto 20mg doesn’t work /TS)

A baby presents with poor feeding, lethargy and irritability on examination he has full fontanelle, high pitched cry , fever , apnea and focal neurological signs , neck stiffness Kernig and brudenski sign wer negative Whts the Dx ? Invx? Rx?

Dx meningitis

Invx CT and blood culture

Rx early> 0-2m benzylpencillin IV + cefotaxime Iv >2m ceftriaxone IV + dexamethasone IV

A baby presents with poor feeding, lethargy and irritability on examination he has high pitched cry , fever , apnea and poor feeding , neck stiffness Kernig and brudenski sign wer negative Whts the Dx ? Invx? Rx?

Dx: meningitis

Invx: LP and blood culture

Rx: early 0-2m Iv benzylpenicillin+ cafotaxime >2m Iv dexamethasone + ceftriaxone late CSF result

most common causative organism for meningitis in a 0-2m old

Ecoli , GBS, listeria

Most common causative organism for meningitis in >2m old

HiB, S.pneumoniae, N.meningitis

When is LP contraindicated in meningitis ? (5)

1) signs of >ICP (focal signs, papilloedema, altered consciousness)

2) local skin infection

3) coagulopathy/theombocytopenia

4) seizure / altered mental status

5) space occupying lesion

When do we do CT instead of LP in meningitis

1) signs of > ICP

2) diagnostic uncertainty mass is suspected

Why is LP contraindicated in SOL and >ICP

can cause cerebral herniation

A child presents with poor feeding, lethargy and irritability there is hx of fevers for 2 days on examination he is confused, emotionaly labile and irritated has full fontanelle, high pitched cry , fever >38c , apnea and focal neurological signs , neck stiffness Kernig and brudenski sign wer negative wbc shows >5 cells / microL Whts the Dx ? Invx? Rx?

Dx: Encephalitis

Invx: CT scan and MRI (signs of impending herniation is the detrmining factor in what is first )

Rx: acyclovir 20mg/kg Iv ± Azithromycin (other than HSV ) audiology f/u 6-8 wks

Most common cause of encephalitis in children ?

HSV

When do we refer a patient for strabismus to a pediatric ophthalmologist?

1)Constant strabismus any age

2)Intermittent strabismus >6m

A child presents with recurrent bouts of abdominal pain and facial edema in FHx the mother and aunt have similar symptoms from time to time whats the possible Dx? Invx? Rx?

Dx: hereditary angioedema

Invx: C1 esterase inhibitor level

Rx: conservative

A child presents with recurrent bouts of abdominal pain, facial edema, dysphagia, stridor, hoarse voice and persistent cough in FHx the mother and aunt have similar symptoms from time to time whats the possible Dx? Invx? Rx?

Dx: recurrent angioedema

Invx: C1 esterase inhibitor level

Rx: hospitalization, intubation , C1 esterase inhibitor concentrate

What are two drugs that are risk factors for hereditary angioedema ?

OCPs and NSAIDs

A child comes to the clinic for a checkup is seen to have dropped from the 75th percentile to the 10th percentile he has a hx of meconium during delivery recurrent respiratory infections , night blindness rickets and coagulopathy whats the possible Dx ? Invx ? Rx?

Dx: cystic fibrosis

Invx: sweat chloride test

Rx: nutritional support , chest PT & AB (S aureus & pseudomonas), VIT A D E K

GOR in infant less than 1 year normal or disease ?

Normal

A 1-6month old child presents with eczema on hands and swollen arms after formula feedings Fhx shows asthma and allergies on father side Whts the possible Dx ? Inv? Rx?

Dx: CMPA

Invx: CMPA exclusion for 2wks

Rx: extensively hydrolysed formula/ rice formula

At what age are solids introduced

4 months

Most common causative organism for gastroenteritis

Norovirus

A 5 years old presents with abdominal colicky pain and diarrhea Whts the most possible Dx? Invx?Rx?

Dx: gastroenteritis

Invx: nothing/stool (hx travel bloody IMC)

Rx: initially asses electrolytes and glucose oral reh 10ml/kg/hr > NG reh > IV reh

Breast feeding + ORS

± odansetron

Most accurate measure of dehydration in pediatrics

Weight

A child less than 1 years of age presents with acute bilateral wheezing Whts the possible Dx ?

• viral acute bronchiolitis

A child 1-5 years of age presents with acute bilateral wheezing whats the most possible Dx ? Rx?

Dx: viral acute bronchiolitis

Rx: Mild: Salbutamol 2-6 puffs

mod: 6 puffs every 20 min 3 times

Severe: admit , o2 , salbutamol nebu 6 puffs ipratropium 4 puffs

A child >6yrs presents with acute bilateral wheezing whats the most possible Dx ? Further Invx ? Rx?

Dx: asthma

Invx:Reversible spirometry

Rx: Mild: Salbutamol 12 puffs

Mod: salbutamol 12 every 20 min 3 times after 30 min no improv oral prednisolone

Severe: admit , oxygen , salbutamol nebu 12 puffs and ipratropium 8 puffs

A child >6yrs presents with unilateral wheezing whats the most possible Dx ?

• mucus plugging

• Foreign body

• Pneumothorax

A child 1-5 years of age is f/u in your clinic for a hx of wheezing attack now the parents are concerned wether to continue the medications he was given for the attack or not what is the maintenance management for asthma for this age group ?

(Step wise if one fails add the next to the regimen)

1) salbutamol

2)LCS/montelokust

3)HCS/LCS as is + montelokust

A child 6-11 years of age is f/u in your clinic for a hx of wheezing attack now the parents are concerned wether to continue the medications he was given for the attack or not what is the maintenance management for asthma for this age group ?

(Step wise if one fails add the next to the regimen)

1) salbutamol

2) LCS/ montelokust

3) HCS/ LCS as is + montelokust / LCS as is + ipratropium

A child presents with hx of tachypnea fever cough on examination he appears lethargic unwell whats the possible Dx ? Rx?

CAP (mild/moderate)

High dose oral amoxicillin

A child presents with fever tachypnea on examination he appears lethargic unwell there are crackles in auscultation there is grunting nasal flaring tachycardia altered mental status spo2 <80% and signs of CP Whts the possible Dx ? Invx? Rx?

CAP (severe)

CXR

Iv ceftriaxone and flucloxacillin CPAP/HFNP

What makes a CAP complicated ?

1) parapnuemonic effusions

2) empyema

3) lung abscess

4) necrotizing pneumonia

NIP vaccine at birth

Hep B

NIP vaccination at 2-4 m

DTP

Hep B and HiB

Rota virus and pneumococcal

Meningococcal B (aboriginal)

HIP 6m vaccinations

DTP

Hep B and HiB

When is influenza vaccine given annually

6 months - less than 5 years

5 years with at risk population

HIP 12m vaccines

MMR

Meningiococcal ACWY

Pneumococcal

Meningiococcal B (aboriginal)

HiP 18m vaccine

MMR and varicella

DTP

HiB

HiP 4 years vaccines

DTP

HiP 7 years vaccine ? If you miss it when can you give it ?

HPV

Upto to 25 yrs

Hip 10yrs vaccine

meningiococcal ACWY

Meningiococcal b (spleen related issues)

What are the 2 vaccines that can be given during pregnancy ? At what weeks?

Influenza

Pertusis (20-32wks)

Hip aboriginal 50> years of age vaccine

Shingles

Pneumococcal vaccine

HiP >65yrs vaccine

Shingles

Influenza

HiP >75 years

Pneumococcal