Rutgers PANCE/PANRE Review Course - …Rutgers+BW+Printable+P… · 1 Angel Solomon, MS PA‐C Rutgers PANCE/PANRE Review Course Infant & Childhood Development yGross Motor y3 month

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Angel Solomon, MS PA‐C

Rutgers PANCE/PANRE Review Course

Infant & Childhood DevelopmentGross Motor3 month – head control4 month – roll over6 month – sit independently9 month – crawl12 month – walk18 month – climbs stairs, run24 month – kick ball


Infant & Childhood DevelopmentLanguage2 month – coos6 month – babbles12 month – mama, dada18 month – 4‐20 words24 month – combining words, 50% comprehensible


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Infant & Childhood DevelopmentLanguage cont…3 year – 75% comprehensible4 year – 100% comprehensibleAge 7 or 8 – speech, language, articulations close to adult


Infant & Childhood Development

Social/Fine motor3 month – laugh6 th h f d lf6 month – reaches, feeds self9 month – indicates wants, pincer grasp12 month – imitates, follow 1 step commands


Infant & Childhood DevelopmentSocial/Fine motor cont…18 month – scribbles, feeds self w/spoon, potty training, stacks 3‐4 blocks h f ll d h/d h d24 month – follow 2 step commands, wash/dry hands

3 yr – dresses with supervision


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Newborn & Infant GrowthNewborns may lose up to 10% of their birth weight in the first week of lifeMost regain birth weight in about 10 daysFirst 6 months: gain about 1oz/dayFirst 6 months: gain about 1oz/dayAt 6 months: weigh 2x birth weightAt 12 months: weigh 3x birth weight, height 1.5x birth length


Childhood Growth

After 2 years of age: 2‐3 kg and 5‐7cm/yearAverage 30 month child weighs 30 pounds and is 30 inches tallA ld i h d d i i h Average 4 year‐old weighs 40 pounds and is 40 inches tallWeight LOSS in a child is always suspicious


Abnormal GrowthFailure to ThriveShort Stature


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FTTDefinition: Weight that decreases to below the 3rd/5thpercentile or weight loss that crosses 2 major percentilesCauses:Nonorganic: Environmental/Social is #1 (poverty, poor feeding technique, neglect/abuse, parental mental health)

Organic – Affects every system, 1st 3 months MC due to infection, Metabolic Disease, Congenital Heart Disease, GERD, Milk Protein intolerance, Cystic Fibrosis


FTT‐continuedInitial Eval:History – Identifies cause of in majority of cases (feeding patterns, vomiting, bowel habits, social/emotional/financial stability, development)

Physical focus on signs of organic disease evidence Physical – focus on signs of organic disease, evidence of abuse/neglect, dysmorphic features, skin lesions, heart murmur, abdominal masses, neuro exam

Labs – Cbc, Bun, Cre, Electrolytes, UA C&STreatment – R/O organic cause, Hi calorie diet, Education, Frequent monitoring, If severe require hospitalization, social services


GROWTH DISTURBANCESDistinguish between normal and abnormal conditions

Tools for Evaluation:1. Growth Curves – critical factor in evaluation

2. Target Height – helpful to evaluate growth potentialBoys ‐ [(Mothers Ht in cm + 13) + Father’s Ht in cm] / 2Girls – [Mothers Ht in cm + (Father’s Ht in cm – 13)] / 2

3. Bone Age – measure of skeletal maturation


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SHORT STATURE1. Familial Short Stature2. Constitutional Growth Delay3. Chronic Conditions


SHORT STATURENormal Variants

Familial Short Stature – Normal birth size, deceleration on growth curve first 2 years of life, Normal bone age and puberty, target height is short

Constitutional Growth Delay – Normal birth size, growth pattern similar to familial short stature, Delayed bone age and puberty, “Late bloomers” Target height normal


SHORT STATURE

Chronic conditions

Endocrine – GH Deficiency, Hypothyroidism, Cushing syndrome/diseaseNutritionalSystemic Disease – GI, Renal, Cardiac, Pulmonary, ImmunologyGenetic Syndromes – Turner, Prader‐Willi, Down


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HEENTURIAcute Otitis MediaChronic Otitis Media

AmblyopiaENT Foreign Bodies

Otitis ExternaCroup


VIRAL URICommon in any age group; especially infants and toddlersLasts 7‐10 daysMCC: RhinovirusSymptoms:Symptoms:

Runny nose, nasal congestion, coryza, sneezing, mild conjunctivitis, sore throat, hoarseness, cough. Fever often presents for first 2‐3days

Tx: Cough and cold medications. No antibiotics!!!


OTITIS MEDIAAcute Otitis Media

Suppurative infection of the middle ear cavityMost prevalent in children between 6 and 24 mo

BacterialSt t P i ( t ) Streptococcus Pneumoniae (most common) Haemophilus influenzaMoraxella Catarrhalis

Viral Respiratory Syncytial VirusRhinovirus Influenza virus


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Otitis MediaRisk Factors

Day Care AttendanceFormula Fed Infants (feeding position)Second hand cigarette smoke

Presentation & DiagnosisOften follows an upper respiratory tract infection(URI) by 1‐7 daysUsually presents with fever, poor feeding, pain and/or irritability, vomiting, ear pulling

TM : bulging, red, landmarks not visualized, immobile (Pneumatic Otoscopy with evaluation of movement of TM)

AntibioticsDOC: Amoxicillin 80‐90 mg/kg/d (erythromycin if allergic) If tx failure after 48 hours: amoxicillin/clavulanate, cefuroxime, cefdinir, ceftriaxoneComplications: mastoiditis Rutgers PANCE/PANRE Review Course

Chronic Otitis MediaDefinition – recurring or persistent infection or inflammation for several months

Risk Factors ‐multiple ear infections, allergies, trauma, swelling of the adenoids

Sx h i l t h hSx – hearing loss, otorrhea, pressure, ear achePE: infxn, air‐fluid levels. discharge, perforationTx: Abx, Surgery (Myringotomy/Repair/Adenoids)Complications: Mastoiditis, Deafness


OTITIS EXTERNAInflammation of the skin in the outer ear canalCommonly caused by water trapped in the canal from swimming in lakes or poolsPathogens:

Staphylococcus aureusp yPseudomonas aeruginosa

Symptoms:Pain, purulent discharge, pain elicited with traction on pinna or tragus

Treatment:Topical Antibiotic/Corticosteroid drops(Acetic Acid/Polymyxin B/Neomycin/Quinolone)


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Viral Croup

Viral Croup – Laryngotracheobronchitis

Most common cause of stridor in children

Peak ages : 6 months to 3 years. Fall/WinterPeak ages : 6 months to 3 years. Fall/Winter• Sx: Barking cough, URI symptoms, hoarseness, fever, inspiratory stridorPathogen: parainfluenza virus commonDiagnosis: H & P, season helpful (Fall/Winter)

<50% “steeple sign on ant neck X‐rayTreatment: Hydration, Humidity! Steroids, Racemic Epinephrine


AMBLYOPIA

Definition: decreases or loss of vision in one or both eyes in the absence of ocular or CNS pathologyInitiated by any condition that results in abnormal/unequal visual input between the “critical period” of birth to 8‐9 years of age

Dx: Visual Acuity, RF ie.. Strabismus, congenital cataracts, FHxTx: Patching, essential within the critical period; otherwise loss may be permanent


Courtesy of WikepediaRutgers PANCE/PANRE Review Course

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AMBLYOPIA

Definition: decreases or loss of vision in one or both eyes in the absence of ocular or CNS pathologyInitiated by any condition that results in abnormal/unequal visual input between the “critical period” of birth to 8‐9 years of age

Dx: Visual Acuity, RF ie.. Strabismus, congenital cataracts, FHxTx: Patching, essential within the critical period; otherwise loss may be permanent


ENT FOREIGN BODIES

Commonly seen: Buttons, beads, marbles, nuts, toy parts, Bugs tooEar: Ear pain, drainage, hearing lossNose: Unilateral purulent rhinitis, persistent sinusitis blocked nasal passage on examsinusitis, blocked nasal passage on examRemoval: Do not blindly probe! If visible, forceps, curette, Foley (inflated past foreign body), etc Restraint is essential to prevent further injury


When treating clinical croup, you could reasonably include all of the following except:

1. IV steroids2. Intubation

R i

84%


3. Racemic epinephrine

4. Oxygen and cool mist

5. IV Ceftriaxone IV steroids

Intubation

Racemic epinephrine

Oxygen and cool mist

IV Ceftriaxone

0%

16%

0%0%

10

A 15 month old male presents with a 2 day history of upper respiratory infection type symptoms followed by a barky cough and low grade fever. Which of the following is the most appropriate management of this patient?

1. Albuterol2. Racemic L‐

33%

42%


epinephrine3. Intubation for

ventilatory support4. IV Antibiotics5. Dexamethasone IV,

IM or PO Albuterol

Racemic L‐epinephrine

Intubation for ventilator...

IV Antibiotics

Dexamethasone IV, IM

..

20%

4%0%

An 18 month old male is brought to the emergency department because he has had a fever and cough for the past 3 days. PE shows an ill appearing but well hydrated child with a bright red tympanic membrane and green discharge from the nose. Temp is 103F. CXR is negative. Which of the following is the most likely dx?

1. Serous otitis media2 Acute otitis media

93%


2. Acute otitis media3. Chronic otitis media4. External otitis media5. Cholesteatoma

Serous otitis m

edia

Acute otitis media

Chronic otitis m

edia

External otitis media

Cholesteatoma

2% 0%0%5%

LungsBronchiolitisPneumonia

Virall

Hyaline Membrane DiseaseCystic FibrosisForeign bodies

BacterialAtypical

Pertussis


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BRONCHIOLITIS

The most common lower respiratory illness in infants and young children less than 2 years old.Pathogen: Respiratory Syncytial Virus(RSV) in 50‐90% of casesSymptoms: Cough, mild fever, tachypnea, and wheezing.

Thick nasal congestiongDiagnosis: RSV antigen nasal wash. CXR ‐ Hyperinflation

WBC ‐ Increases lymphocytesTreatment: Controversial

Nebulized albuterol commonly usedOral steroids if sx severeRibavirin has been used in hospitalized casesSynagis now used to prevent RSV in preemies


PNEUMONIA ‐ VIRALCommon in all age groups; follows URIEtiology:

MCC of pneumonia in children. RSV (MC), parainfluenza, & influenza viruses

Symptoms:URI precedes onset of cough Wheezing, grunting, nasal flaring common

Labs:WBC may be low, normal, or slightly elevated. A high WBC makes viral etiology unlikely

Imaging:CXR may show perihilar streaking, increased interstitial markings, peribronchial cuffing

Treatment:It is rarely possible to reliably differentiate viral from bacterial pneumonia based upon history, exam, labs or radiographsTherefore it is common for appropriate concomitant antibiotic coverage to be used for viral pneumonia in children Rutgers PANCE/PANRE Review Course

PNEUMONIA ‐ BACTERIALInflammation of the lung classified according to the infecting organism and siteOccurs in all age groups, but more commonly in children < 2 years oldCommon pathogens:

S. pneumoniae, Group A strepG B t ( t )Group B strep (neonates)

Symptoms:URI precedes abrupt onset of fever, chills, SOB, anorexia, cough, dyspneaN/V, abdominal/chest/shoulder pain typical, malaise


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Pneumonia ‐ BacterialSigns:

tachypnea: reliable sign of pneumonia in kids!Cough, grunting, nasal flaring, Exam usually shows decreased breath sounds, rales, dullness to percussion, but can be normalWheezing unusual in bacterial pneumonia unless pt has baseline reactive airway disease

Labs:WBC >15,000 or greaterBlood cultures positive in 10‐15% of cases

Imaging:Lobar consolidation, patchy infiltrates commonMay see effusionsAtelectasis vs infiltrate ‐ often hard to tell

Treatment:Neonates: IV ampicillin/gentamycinOthers: penicillin. Amoxicillin, 2nd or 3rd generation cephalosporin


PNEUMONIA ‐ ATYPICALChlamydia pneumonia

Occurs between 2 weeks to 6 months of age. Peak incidence (>90%) by 8 weeksMost common cause of pneumonia in children under 6 months of age (25‐45% of cases)Pathogen: C trachomatis (maternal STD)Pathogen: C. trachomatis (maternal STD)URI prodrome; nearly 100% afebrileStaccato cough, tachypnea, rales, conjunctivitisDx: Nasal wash, eosinophilia commonTx: Erythromycin. Hospitalization for those with paroxysmal cough, apnea, resp distress


Pneumonia ‐ AtypicalMycoplasma pneumonia:

Common over the age of 5 years, esp teensPathogen: Mycoplasma pneumoniaLong incubation: 2‐3 weeks

Symptoms: Gradual onset, Dry cough, progressing to productive. Fever, HA, malaise, Signs: Rales, bullous myringitisCXR: Middle and lower lobe infiltratesTx: Macrolides usually shorten course and may lessen severity of symptoms


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PERTUSSIS“Whooping Cough”

Infants/toddlers; un‐/partially immunizedPathogen: Bordetella pertussis

Spread by teens/adults who are no longer immune

Sx: 3 stages3 gCattarhal: URI (1‐2 weeks)Paroxysmal: Staccato cough and ‘whoop’ on inspiration(1‐2 weeks)Convalescent: Dry cough (1‐2 weeks)

Dx: Hx, characteristic paroxysmal coughGold standard‐Nasopharyngeal culture, PCR

Tx: ErythromycinRutgers PANCE/PANRE Review Course

Hyaline Membrane DiseaseCause: Deficiency of surfactantS&S: increased RR, cyanosis, expiratory gruntingD CXR h h i B/L t l t iDx: CXR shows hypoexpansion, B/L atelectasis

“Ground glass” “Air bronchograms”

Tx: Oxygen, early intubation, ventilationSurfactant replacement


CYSTIC FIBROSISMost common severe inherited disease in the Caucasian population ‐ 1:2500Resp symptoms: chronic cough or sinusitis, recurrent pneumonia, nasal polyps, clubbingGI symptoms: meconium ileus (20%), pancreatic insufficiency (85%) failure to thriveinsufficiency (85%), failure to thriveDx: Sweat chloride is the “gold standard” >60meq/L is abnormal. Genetic testingTx: ATB, pancreatic enzymes, bronchodilators, postural drainage. Mean survival age is increasing!


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RESPIRATORY FOREIGN BODIES

Throat: Stridor, choking, cyanosis. (Can also occur if foreign body is in esophagus)Ball‐valve effect may cause hyperinflationHeimlich if suspected upper airway FB and respiratory distressRi id b h if i l iRigid bronchoscopy if in lower airway.


End of Pediatrics OneEnd of Pediatrics OnePlease go on to Pediatrics Two


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CardiologyAcquired Heart Disease

Rheumatic FeverFunctional murmurs

Still’s MurmurVenous Hum

Congenital Heart DiseaseAcyanotic LesionsCyanotic Lesions


RHEUMATIC FEVERInflammatory disease triggered by Group A strep and can cause permanent damage to heart muscle and valvesAffects ages 5‐15 yearsJones criteria: Major ‐ carditis, polyarthritis, chorea,

erythema marginatum, subcutaneous nodules Minor ‐ fever, arthralgia, elevated ESR and/or , g , /C‐reactive protein,, prolonged PR interval on ECG

Dx: 2 major criteria OR 1 major and 2 minorTx: Bed rest, salicylates, steroids for severe carditis, chlorpromazine or Haloperidol for choreaPrevention: Recurrences ‐ Benzathine penicillin q month


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FUNCTIONAL MURMURS

Still’s murmurMost common innocent murmur of childhoodUsually age 2 years to adolescenceLoudest apex to LSB. Musical or vibratory, high pitched, I‐III early systolicdiminishes with sitting/standing/Valsalvadiminishes with sitting/standing/Valsalva

Venous HumVery common after age 3 yearsProduced by turbulence in subclavian and jugular veinsContinuous, musical, I‐II at upper R, LS, & lower neckDisappears if supine or jugular vein compression


Cardiology Acyanotic lesions

Atrial Septal Defect (ASD)Ventricular Septal Defect (VSD)

Most common form of congenital heart diseaseOccurs in about 2 per 1000 live birthsOccurs in about 2 per 1000 live birthsLoud, holosystolic murmur along LSB

Atrioventricular Septal Defect (AVSD)Patent Ductus Arteriosus (PDA)Coarctation of the Aorta

BP in upper extremity 20mmHg or greater than lower extremity


Atrial Septal DefectCommunication between right and left atriachildren asymptomaticS2 widely split and fixedT i l iTx: surgical repair


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Ventricular Septal DefectMost common congenital heart diseaseCommunication between left and right ventriclesSmall VSD ‐ asymptomaticL VSD t t 6 k i ti h t f ilLarge VSD ‐ present at 4‐6 weeks in congestive heart failureloud, harsh, holosystolic murmur along the lower left sternal borderTx: control CHF, surgery if unresponsive to meds


Patent Ductus ArteriosusPresence in fetal life allows blood from the pulmonary artery to flow to the aorta, bypassing the nonaerated fetal lungsusually closes spontaneously by 3‐5 days of lifeRF: prematurity, female, maternal rubellaS M iSx: Most are asymptomaticMachinery murmur that is continuous and maximal at 2nd intercostal space, bounding peripheral pulses, wide pulse pressureTx: Medical management ie Indomethacin in preemies, cardiac cath in full term infants, may require surgical correction


Coarctation of the AortaNarrowing of the aortic lumenMore common in malesSx: CHF, HTNDx: 1 pulses greater in upper extremitiesDx: 1. pulses greater in upper extremities

2. BP of upper extremity is > than lower extremity by 20 mm Hg

3. blowing systolic murmur in left axillaX‐ray: notching of the ribs in older kidsTx: Surgical correction


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Cyanotic Lesions

Tetralogy of FallotVSDPulmonary stenosisOverriding AortaRVH

Tricuspid AtresiaTransposition of the Great VesselsTotal Anomalouus Pulmonary Venous ReturnTruncus Arteriosus


Tetralogy of FallotMost common type of cyanotic heart lesion4 components: VSD, pulmonary stenosis, overriding aorta, right ventricular hypertrophysudden cyanosis dyspnea on exertion hypoxemic spells sudden cyanosis, dyspnea on exertion ‐ hypoxemic spells aka “tet spells”rough, systolic ejection murmur 3rd intercostal spaceX‐ray: Boot shaped heartTx: Medical then surgical by 18 months


Courtesy of Wikipedia Rutgers PANCE/PANRE Review Course

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Tetralogy of FallotMost common type of cyanotic heart lesion4 components: VSD, pulmonary stenosis, overriding aorta, right ventricular hypertrophysudden cyanosis dyspnea on exertion hypoxemic spells sudden cyanosis, dyspnea on exertion ‐ hypoxemic spells aka “tet spells”rough, systolic ejection murmur 3rd intercostal spaceX‐ray: Boot shaped heartTx: Medical then surgical by 18 months


A 2 year old is brought to the ED by his mother w/ sudden onset of choking, gagging, coughing and wheezing. Vital signs are: Temp: 37C(98.6F) Pulse: 120/min, Resp: 28/min The physical exam reveals decreased breath sounds over the right lower lobe w/ inspiratory rhonchi and localized exp wheezing. CXR reveals nlinspiratory views, but exp views show localized hyperinflation, with mediastinal shift to the left. Which of the following is the most likely diagnosis?

A h

98%


1. Asthma2. Epiglottitis3. Foreign body

aspiration4. Pulmonary embolism5. Viral pneumnia As

thma

Epiglottitis

Foreign body aspiration

Pulmonary em

bolism

Viral pneumnia

0% 0% 0%2%

A 6 month old comes to your office during the winter looking mildly ill with a fever of 100.7 and a RR of 72. He has wheezing throughout his chest and scattered rales and rhonchi. Your working dx is:

1. Heart failure2 Bronchiolitis

93%


2. Bronchiolitis3. Croup4. Epiglottitis5. Pneumonia

Heart failure

Bronchiolitis

Croup

Epiglottitis

Pneumonia

0%7%

0%0%

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An 18 month old documented as less than tenth percentile on your growth chart is having trouble breathing. He has a history of intermittent dyspnea and a chronic cough since birth. Post delivery, the patient did not defecate for quite some time. Which of the following diagnostic tests will be most useful in this child’s evaluation?

1. Rectal biopsy2. Chest X‐ray

100%


3. Urine glucose assessment

4. Urine protein assessment

5. Sweat test Rectal biopsy

Chest X‐ray

Urine glucose assessm

ent

Urine protein assessm

ent

Sweat test

0% 0% 0%0%

Which of the following congenital heart defects is associated with cyanosis?

1. Patent ductus arteriosus

2. Atrial septal defect3 Ventricular septal

98%


3. Ventricular septal defect

4. Coarctation of the aorta

5. Tetralogy of Fallot

Patent ductus arteriosus

Atrial septal defect

Ventricular septal defect

Coarctation of the aorta

Tetralogy of Fallot

0% 0% 0%2%

Gastrointestinal/Nutrition Pyloric StenosisIntussusceptionPKUGI foreign bodies


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PYLORIC STENOSIS

Hypertrophy of muscular layers of pylorus leading to obstruction, B i b t k R t bi th Begins between ages 2‐4 weeks. Rare at birth or over the age of 6 monthsMuch more common in malesClassic presentation “Projectile, non‐bilious vomiting and palpable pyloric mass or “olive”.Well, hungry childDx: Physical exam, ultrasound. Tx: Surgery


INTUSSUSCEPTIONInvagination of part of the bowel into an adjacent part of the bowelMost cases idiopathic; males>femalesMost common from 6 12 months of ageMost common from 6‐12 months of ageSx: Paroxysmal abdominal pain is main symptom, followed by vomiting and diarrhea“Currant‐jelly” stool in 50% of casesExam: Sausage‐shaped massTx: Reduction (Barium enema) and/or open surgery


PKUCause: Dec activity of phenylalanine hydroxylase (enzyme that converts phenylalanine to tyrosine)S&S: severe mental retardation, hyperactivity, seizures, light complexion, urine w/mouse‐like odorD I d h l l i D d iDx: Increased phenylalanine, Decreased tyrosineTx: Limit dietary phenylalanine


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GI FOREIGN BODIESCoins, toys, and batteries are most commonUpper esophagus ‐ remove to lower risk of aspiration (Foley catheters often used)Lower esophagus remove if > 24 hoursLower esophagus ‐ remove if > 24 hoursStomach ‐ < 3‐5 cm usually pass GI tractIf object is sharp or caustic (open safety pin, camera batteries) ‐ endoscopy.If toxic (medication tablets) ‐ lavage


A 12 year old accidentally swallowed a broken tab from an aluminum soft drink more than 6 hours ago. She can swallow liquids but solids cause discomfort. On X‐ray, a flat metallic object is located at the level of the aortic arch. Which of the following is the most appropriate course of action:

1. Admission for surgical extraction

2. Removal of tab by endoscopy

83%


endoscopy3. Extract with Fogarty

catheter4. Gastrogafin swallow to

r/o esophageal injury5. Observation of the

patient’s stool for passage of tab

Admission for surgical ex...

Removal of tab by endo...

Extract with Fogarty cat...

Gastrogafin swallow to r..

Observation of the patie...

2%11%

0%4%

Which of the following findings is most suggestive of a diagnosis of pyloric stenosis in an infant?

1. Epigastric mass2. Failure to thrive3 Projectile vomiting

43%

57%


3. Projectile vomiting4. Abdominal

distention

Epigastric mass

Failure to thrive

Projectile vomiting

Abdominal distention

0%0%

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OrthopedicsClassification of fracturesCongenital Hip DysplasiaSCFEOsgood‐SchlatterNursemaid’s Elbow


Salter‐Harris ClassificationType I ‐ Epiphyseal separation through the physisType II ‐ Fracture through a portion of the physis but exiting across the metaphysisType III Fracture through the physis but exiting across the Type III ‐ Fracture through the physis but exiting across the epiphysis into the jointType IV ‐ Fracture through metaphysis, physis, and epiphysisCrush injury to the physis


S A

Reproduced with permission of author, Dr Frank Gaillard L T R


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CONGENITAL HIP DYSPLASIA(Developmental Dislocation of the Hip)

Increased risk in first‐born females, breech birth, or family history of DDHDx: Screening exam essential at each visitOrtolani (Out) test ‐ Abduct/external rotation Palpable click as dislocation reducedBarlow test: Adduct/Internal rotation Palpable click as hip dislocatesPhysical Exam: Assymetric thigh foldsUltrasound under 3 months. X‐rays if olderTx: Harness. SurgeryComplications: (untreated) Limp, pain, degenerative disease of hip Above image courtesy of wikipediaRutgers PANCE/PANRE Review Course

SCFE: Slipped Capital Femoral Epiphysis

F l h d “ li ” i h i d i Femoral head “slips” ‐ exposing the anterior and superior aspects of the femoral neckMales (14‐16 yrs) > Females (11‐13 yrs)Associated with obesity, increased height, genital underdevelopment, pituitary tumorsSx: Acute or chronic hip or knee painX‐ray pearl: Ice cream falling off the coneTx: Surgery

Above image courtesy of www.expertconsult.com Rutgers PANCE/PANRE Review Course

OSGOOD‐SCHLATTER SYNDROMEFibrocartilage microfracture of the patellar ligamentMost common in adolescent malesActivity related pain lasts 12‐24 hrsTenderness, thickening at tibial tubercletubercleX‐rays: Prominent, irregular. Fx?Tx: Rest, ice, compression, NSAIDS


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NURSEMAID’S ELBOWSubluxation of the Radial Head

Occurs after forearm or wrist is jerked with longitudinal/pronational forces (“airplane”)C t ti Child h ld i Common presentation: Child holds arm in pronated and flexed position and resists extension

Dx: History, exam. Radiographs are normalTx: Reduction by supinating/extending arm. Splint if recurrent. Prevention

Above image courtesy of wikepediaRutgers PANCE/PANRE Review Course

SkinMeaslesMumpsRubellaVaricellaRoseolaRoseolaErythema infectiosumHand‐foot‐mouth diseaseKawasaki syndromeReview Immunization schedule


Measles: Rubeola

Morbillivirus in the Paramyxovirus familyRare at any ageIncubation: 8‐12 days for sx, 14 days for rashProdrome: fever (101+), cough, coryza, conjunctivitis Koplik spots Rash: Neck & Abdomen first ‐maculopapularTx: Primarily supportive


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Courtesy of Centers for Disease Control and Prevention


“Mumps: “Parotitis”ParamyxovirusIncubation 12‐25 daysLate winter & springPain & swelling in front of and below earOften testicular pain within 1 weekComplete recovery with supportive care in 1‐2 weeks is the rule

Image above courtesy of Centers for Disease Control and Prevention


Rubella: “German measles

Rubella virus is a togavirus; RubivirusRare at any ageCongenital rubella is deadly, especially in the first trimester, TRIAD: deafness, cataracts, cardiac defectsDescription: Blueberry muffin babyA i d E th t h i f h d Acquired: Erythematous rash progressing from head to toesPREVENTION!

Courtesy of wikepedia


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Varicella: “Chicken Pox”

Varicella‐zoster virus Usually 5 to 9 yrs oldLate winter/early springIncubation: 10‐21 daysVesicular, erythematous rash on torso, then face and extremitiesDescription: “Dew drops on a rose petal”Tx is supportive


Courtesy of Centers for Disease Control and Prevention


Rutgers PANCE/PANRE Review CourseCourtesy of Centers for Disease Control and Prevention

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Roseola: “Roseola infantum”HHV‐6Ages 3 months ‐ 4 yearsIncubation 5‐15 daysMaculopapular rashHigh fever (102‐105) for 3‐5 daysFever starts resolving, THEN rash appearsTx is supportive


Erythema infectiosum:“Fifth Disease” or“Slapped Cheek Syndrome

ParvovirusSchool aged childrenIncubation 4‐14 daysRed facial rash and lacy, pink macular rash on torso & extremitiesPregnant woman at risk: hydrops fetalisTx is supportive


Courtesy of WikepediaRutgers PANCE/PANRE Review Course

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Courtesy of wikepediaRutgers PANCE/PANRE Review Course

Hand‐Foot‐and‐Mouth DiseaseCoxsackie A16 virus (most common)Under 5 yearsIncubation 3 ‐ 7 daysLate summer & fallPainful oral ulcers, low grade fever, gray‐red vesicles on hands and feetTx is supportive

DDx: Herpangina/Gingivostomatitis


Courtesy of Dr. William Sears, www.askdrsears.com Rutgers PANCE/PANRE Review Course

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Courtesy of Dr. William Sears, www.askdrsears.com


Courtesy of Dr. William Sears, www.askdrsears.comRutgers PANCE/PANRE Review Course

Kawasaki Syndrome/Disease“Mucocutaneous Lymph Node Syndrome

Etiology unknown ‐ infectious agent likelyUnder 5 years oldFever > 5 days AND four of the following: conjunctivitis, rash, mucosal changes, edema of hands/feet, cervical adenopathy > 1.5 cmComplications: anuerysmsTx: IVIG, Aspirin


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Recommended Childhood Immunization Schedule, United States

RotavirusHepatitis ApVaricellaPertussisMeningococcalHuman papilloma virus


Six days ago, a 2‐year‐old boy had a temperature of 40.0°C (104.0°F). No specific cause was found. His fever has persisted and he now has injected conjunctivae, strawberry tongue, dry fissured lips, erythema and desquamation of his hands and feet, and bilateral cervical adenopathy. Which of the following is the most likely complication of this condition?

1. Chorea2. Congestive heart

91%

gfailure

3. Coronary artery aneurysm

4. Mesenteric arteritis5. Valvular heart disease


Chorea

Congestive hea...

Coronary arter...

Mesenteric art...

Valvular heart...

5%0%

5%0%

An 18‐month‐old boy is brought to the emergency department because he has had fever and cough for the past three days. While in the waiting room, he has a generalized tonic‐clonic seizure that lasts five minutes. He has no history of a seizure disorder. Physical examination shows a postictal child with a bright red tympanic membrane and green discharge from the nose. Temperature is 40.6°C (105.0°F). Which of the following is the most appropriate initial diagnostic study?

1. CT scan

59%

2. Electroencephalography3. Lumbar puncture4. MRI scan5. Myelography


CT scan

Electroencepha...

Lumbar punctur...

MRI scan

Myelography

30%

9%

0%2%

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A previously healthy 15‐month‐old boy becomes anxious and begins crying and drooling copiously. A few minutes earlier he had been calmly playing with his toys. Temperature is 36.7°C (98.1°F), pulse rate is 84/min, and respirations are 18/min. On physical examination, the posterior pharynx is mildly injected but otherwise clear. The lungs are clear to auscultation and percussion. Findings on chest x‐ray study are normal. Within an hour he is calmer, but he continues to drool heavily. Which of the following is the most appropriate next step?

1. Administration of syrup of ipecac

68%

ipecac2. Barium swallow x‐ray study3. Chest physical therapy4. Esophagogastroduodenoscopy5. Insertion of a nasogastric tube


Administration

of syrup ..

Barium

swallow x‐ray study

Chest physical therapy

Esophagogastroduoden...

Insertion of a nasogastri...

5%

20%

8%0%


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