Angel Solomon, MS PA-C Rutgers PANCE/PANRE Review Course
Angel Solomon, MS PA-C
Rutgers PANCE/PANRE Review Course
Infant & Childhood Development Gross Motor
3 month – head control
4 month – roll over
6 month – sit independently
9 month – crawl
12 month – walk
18 month – climbs stairs, run
24 month – kick ball
Rutgers PANCE/PANRE Review Course
Infant & Childhood Development Language
2 month – coos
6 month – babbles
12 month – mama, dada
18 month – 4-20 words
24 month – combining words, 50% comprehensible
Rutgers PANCE/PANRE Review Course
Infant & Childhood Development Language cont…
3 year – 75% comprehensible
4 year – 100% comprehensible
Age 7 or 8 – speech, language, articulations close to adult
Rutgers PANCE/PANRE Review Course
Infant & Childhood Development
Social/Fine motor
3 month – laugh
6 month – reaches, feeds self
9 month – indicates wants, pincer grasp
12 month – imitates, follow 1 step commands
Rutgers PANCE/PANRE Review Course
Infant & Childhood Development Social/Fine motor cont…
18 month – scribbles, feeds self w/spoon, potty training, stacks 3-4 blocks
24 month – follow 2 step commands, wash/dry hands
3 yr – dresses with supervision
Rutgers PANCE/PANRE Review Course
Newborn & Infant Growth
Newborns may lose up to 10% of their birth weight in the first week of life
Most regain birth weight in about 10 days
First 6 months: gain about 1oz/day
At 6 months: weigh 2x birth weight
At 12 months: weigh 3x birth weight, height 1.5x birth length
Rutgers PANCE/PANRE Review Course
Childhood Growth
After 2 years of age: 2-3 kg and 5-7cm/year
Average 30 month child weighs 30 pounds and is 30 inches tall
Average 4 year-old weighs 40 pounds and is 40 inches tall
Weight LOSS in a child is always suspicious
Rutgers PANCE/PANRE Review Course
Abnormal Growth Failure to Thrive
Short Stature
Rutgers PANCE/PANRE Review Course
FTT
Definition: Weight that decreases to below the 3rd/5th percentile or weight loss that crosses 2 major percentiles
Causes:
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
Rutgers PANCE/PANRE Review Course
FTT-continued Initial 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 of abuse/neglect, dysmorphic features, skin lesions, heart murmur, abdominal masses, neuro exam
Labs – Cbc, Bun, Cre, Electrolytes, UA C&S
Treatment – R/O organic cause, Hi calorie diet, Education, Frequent monitoring, If severe require hospitalization, social services
Rutgers PANCE/PANRE Review Course
GROWTH DISTURBANCES Distinguish between normal and abnormal conditions
Tools for Evaluation:
1. Growth Curves – critical factor in evaluation
2. Target Height – helpful to evaluate growth potential
Boys - [(Mothers Ht in cm + 13) + Father’s Ht in cm] / 2
Girls – [Mothers Ht in cm + (Father’s Ht in cm – 13)] / 2
3. Bone Age – measure of skeletal maturation
Rutgers PANCE/PANRE Review Course
SHORT STATURE 1. Familial Short Stature
2. Constitutional Growth Delay
3. Chronic Conditions
Rutgers PANCE/PANRE Review Course
SHORT STATURE
Normal 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
Rutgers PANCE/PANRE Review Course
SHORT STATURE
Chronic conditions
Endocrine – GH Deficiency, Hypothyroidism, Cushing syndrome/disease
Nutritional
Systemic Disease – GI, Renal, Cardiac, Pulmonary, Immunology
Genetic Syndromes – Turner, Prader-Willi, Down
Rutgers PANCE/PANRE Review Course
HEENT URI
Acute Otitis Media
Chronic Otitis Media
Otitis Externa
Croup
Amblyopia
ENT Foreign Bodies
Rutgers PANCE/PANRE Review Course
VIRAL URI Common in any age group; especially infants and
toddlers
Lasts 7-10 days
MCC: Rhinovirus
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!!!
Rutgers PANCE/PANRE Review Course
OTITIS MEDIA Acute Otitis Media
Suppurative infection of the middle ear cavity
Most prevalent in children between 6 and 24 mo
Bacterial
Streptococcus Pneumoniae (most common)
Haemophilus influenza
Moraxella Catarrhalis
Viral
Respiratory Syncytial Virus
Rhinovirus
Influenza virus
Rutgers PANCE/PANRE Review Course
Otitis Media
Risk Factors Day Care Attendance
Formula Fed Infants (feeding position)
Second hand cigarette smoke
Presentation & Diagnosis Often follows an upper respiratory tract infection(URI) by 1-7 days
Usually 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)
Antibiotics DOC: Amoxicillin 80-90 mg/kg/d (erythromycin if allergic) If tx
failure after 48 hours: amoxicillin/clavulanate, cefuroxime, cefdinir, ceftriaxone
Complications: mastoiditis Rutgers PANCE/PANRE Review Course
Chronic Otitis Media Definition – recurring or persistent infection or
inflammation for several months
Risk Factors - multiple ear infections, allergies, trauma, swelling of the adenoids
Sx – hearing loss, otorrhea, pressure, ear ache
PE: infxn, air-fluid levels. discharge, perforation
Tx: Abx, Surgery (Myringotomy/Repair/Adenoids)
Complications: Mastoiditis, Deafness
Rutgers PANCE/PANRE Review Course
OTITIS EXTERNA Inflammation of the skin in the outer ear
canal
Commonly caused by water trapped in the canal from swimming in lakes or pools
Pathogens:
Staphylococcus aureus
Pseudomonas aeruginosa
Symptoms:
Pain, purulent discharge, pain elicited with traction on pinna or tragus
Treatment:
Topical Antibiotic/Corticosteroid drops
(Acetic Acid/Polymyxin B/Neomycin/Quinolone)
Rutgers PANCE/PANRE Review Course
Viral Croup
Viral Croup – Laryngotracheobronchitis
Most common cause of stridor in children Peak ages : 6 months to 3 years. Fall/Winter • Sx: Barking cough, URI symptoms, hoarseness, fever,
inspiratory stridor Pathogen: parainfluenza virus common Diagnosis: H & P, season helpful (Fall/Winter)
<50% “steeple sign on ant neck X-ray Treatment: Hydration, Humidity! Steroids, Racemic
Epinephrine
Rutgers PANCE/PANRE Review Course
AMBLYOPIA
Definition: decreases or loss of vision in one or both eyes in the absence of ocular or CNS pathology
Initiated 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, FHx
Tx: Patching, essential within the critical period; otherwise loss may be permanent
Rutgers PANCE/PANRE Review Course
Courtesy of Wikepedia Rutgers PANCE/PANRE Review Course
ENT FOREIGN BODIES
Commonly seen: Buttons, beads, marbles, nuts, toy parts, Bugs too
Ear: Ear pain, drainage, hearing loss
Nose: Unilateral purulent rhinitis, persistent sinusitis, blocked nasal passage on exam
Removal: Do not blindly probe! If visible, forceps, curette, Foley (inflated past foreign body), etc Restraint is essential to prevent further injury
Rutgers PANCE/PANRE Review Course
Which of the following is the most common presenting symptom of epiglottitis in a child?
Rutgers PANCE/PANRE Review Course
Early
morn
ing s
putum
...
Muffl
ed phonatio
n
Bar
king co
ugh
Rhin
orrhea
0% 0%0%
100%1. Early morning sputum production
2. Muffled phonation
3. Barking cough
4. Rhinorrhea
When treating clinical croup, you could reasonably include all of the following except:
Rutgers PANCE/PANRE Review Course
IV st
eroid
s
Intu
bation
Race
mic
epinephrin
e
Oxyg
en and cool m
ist
IV C
eftria
xone
0%
16%
84%
0%0%
1. IV steroids
2. Intubation
3. Racemic epinephrine
4. Oxygen and cool mist
5. IV Ceftriaxone
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?
Rutgers PANCE/PANRE Review Course
Alb
utero
l
Race
mic
L-epin
ephrine
Intu
bation fo
r ventil
ator..
.
IV A
ntibio
tics
Dexa
meth
asone IV
, IM
..
20%
33%
42%
4%0%
1. Albuterol
2. Racemic L-epinephrine
3. Intubation for ventilatory support
4. IV Antibiotics
5. Dexamethasone IV, IM or PO
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?
Rutgers PANCE/PANRE Review Course
Sero
us otit
is m
edia
Acu
te o
titis
media
Chro
nic otit
is m
edia
Exte
rnal o
titis
media
Chole
steato
ma
2%
93%
0%0%5%
1. Serous otitis media
2. Acute otitis media
3. Chronic otitis media
4. External otitis media
5. Cholesteatoma
Lungs Bronchiolitis
Pneumonia
Viral
Bacterial
Atypical
Pertussis
Hyaline Membrane Disease
Cystic Fibrosis
Foreign bodies
Rutgers PANCE/PANRE Review Course
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 cases
Symptoms: Cough, mild fever, tachypnea, and wheezing. Thick nasal congestion
Diagnosis: RSV antigen nasal wash. CXR - Hyperinflation WBC - Increases lymphocytes
Treatment: Controversial Nebulized albuterol commonly used
Oral steroids if sx severe
Ribavirin has been used in hospitalized cases
Synagis now used to prevent RSV in preemies
Rutgers PANCE/PANRE Review Course
PNEUMONIA - VIRAL Common in all age groups; follows URI
Etiology: 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 radiographs
Therefore it is common for appropriate concomitant antibiotic coverage to be used for viral pneumonia in children
Rutgers PANCE/PANRE Review Course
PNEUMONIA - BACTERIAL Inflammation of the lung classified according to the infecting
organism and site
Occurs in all age groups, but more commonly in children < 2 years old
Common pathogens:
S. pneumoniae, Group A strep
Group B strep (neonates)
Symptoms:
URI precedes abrupt onset of fever, chills, SOB, anorexia, cough, dyspnea
N/V, abdominal/chest/shoulder pain typical, malaise
Rutgers PANCE/PANRE Review Course
Pneumonia - Bacterial Signs:
tachypnea: reliable sign of pneumonia in kids!
Cough, grunting, nasal flaring,
Exam usually shows decreased breath sounds, rales, dullness to percussion, but can be normal
Wheezing unusual in bacterial pneumonia unless pt has baseline reactive airway disease
Labs: WBC >15,000 or greater
Blood cultures positive in 10-15% of cases
Imaging: Lobar consolidation, patchy infiltrates common
May see effusions
Atelectasis vs infiltrate - often hard to tell
Treatment: Neonates: IV ampicillin/gentamycin
Others: penicillin. Amoxicillin, 2nd or 3rd generation cephalosporin
Rutgers PANCE/PANRE Review Course
PNEUMONIA - ATYPICAL Chlamydia pneumonia
Occurs between 2 weeks to 6 months of age. Peak incidence (>90%) by 8 weeks
Most common cause of pneumonia in children under 6 months of age (25-45% of cases)
Pathogen: C. trachomatis (maternal STD)
URI prodrome; nearly 100% afebrile
Staccato cough, tachypnea, rales, conjunctivitis
Dx: Nasal wash, eosinophilia common
Tx: Erythromycin. Hospitalization for those with paroxysmal cough, apnea, resp distress
Rutgers PANCE/PANRE Review Course
Pneumonia - Atypical Mycoplasma pneumonia:
Common over the age of 5 years, esp teens
Pathogen: Mycoplasma pneumonia
Long incubation: 2-3 weeks
Symptoms: Gradual onset, Dry cough, progressing to productive. Fever, HA, malaise,
Signs: Rales, bullous myringitis
CXR: Middle and lower lobe infiltrates
Tx: Macrolides usually shorten course and may lessen severity of symptoms
Rutgers PANCE/PANRE Review Course
PERTUSSIS “Whooping Cough”
Infants/toddlers; un-/partially immunized
Pathogen: Bordetella pertussis Spread by teens/adults who are no longer immune
Sx: 3 stages
Cattarhal: URI (1-2 weeks)
Paroxysmal: Staccato cough and ‘whoop’ on inspiration(1-2 weeks)
Convalescent: Dry cough (1-2 weeks)
Dx: Hx, characteristic paroxysmal cough
Gold standard-Nasopharyngeal culture,
PCR
Tx: Erythromycin
Rutgers PANCE/PANRE Review Course
Hyaline Membrane Disease
Cause: Deficiency of surfactant
S&S: increased RR, cyanosis, expiratory grunting
Dx: CXR shows hypoexpansion, B/L atelectasis “Ground glass” “Air bronchograms”
Tx: Oxygen, early intubation, ventilation
Surfactant replacement
Rutgers PANCE/PANRE Review Course
CYSTIC FIBROSIS
Most common severe inherited disease in the Caucasian population - 1:2500
Resp symptoms: chronic cough or sinusitis, recurrent pneumonia, nasal polyps, clubbing
GI symptoms: meconium ileus (20%), pancreatic insufficiency (85%), failure to thrive
Dx: Sweat chloride is the “gold standard” >60meq/L is abnormal. Genetic testing
Tx: ATB, pancreatic enzymes, bronchodilators, postural drainage. Mean survival age is increasing!
Rutgers PANCE/PANRE Review Course
RESPIRATORY FOREIGN BODIES
Throat: Stridor, choking, cyanosis. (Can also occur if foreign body is in esophagus)
Ball-valve effect may cause hyperinflation
Heimlich if suspected upper airway FB and respiratory distress
Rigid bronchoscopy if in lower airway.
Rutgers PANCE/PANRE Review Course
Cardiology Acquired Heart Disease
Rheumatic Fever
Functional murmurs
Still’s Murmur
Venous Hum
Congenital Heart Disease
Acyanotic Lesions
Cyanotic Lesions
Rutgers PANCE/PANRE Review Course
RHEUMATIC FEVER Inflammatory disease triggered by Group A strep and can cause
permanent damage to heart muscle and valves
Affects ages 5-15 years
Jones criteria: Major - carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules Minor - fever, arthralgia, elevated ESR and/or C-reactive protein,, prolonged PR interval on ECG
Dx: 2 major criteria OR 1 major and 2 minor
Tx: Bed rest, salicylates, steroids for severe carditis, chlorpromazine or Haloperidol for chorea
Prevention: Recurrences - Benzathine penicillin q month
Rutgers PANCE/PANRE Review Course
FUNCTIONAL MURMURS
Still’s murmur Most common innocent murmur of childhood Usually age 2 years to adolescence Loudest apex to LSB. Musical or vibratory, high
pitched, I-III early systolic diminishes with sitting/standing/Valsalva
Venous Hum Very common after age 3 years Produced by turbulence in subclavian and jugular
veins Continuous, musical, I-II at upper R, LS, & lower
neck Disappears if supine or jugular vein compression
Rutgers PANCE/PANRE Review Course
Cardiology Acyanotic lesions
Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD) Most common form of congenital heart disease
Occurs in about 2 per 1000 live births
Loud, 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
Rutgers PANCE/PANRE Review Course
Atrial Septal Defect Communication between right and left atria
children asymptomatic
S2 widely split and fixed
Tx: surgical repair
Rutgers PANCE/PANRE Review Course
Ventricular Septal Defect Most common congenital heart disease
Communication between left and right ventricles
Small VSD - asymptomatic
Large VSD - present at 4-6 weeks in congestive heart failure
loud, harsh, holosystolic murmur along the lower left sternal border
Tx: control CHF, surgery if unresponsive to meds
Rutgers PANCE/PANRE Review Course
Patent Ductus Arteriosus Presence in fetal life allows blood from the pulmonary artery to
flow to the aorta, bypassing the nonaerated fetal lungs
usually closes spontaneously by 3-5 days of life
RF: prematurity, female, maternal rubella
Sx: Most are asymptomatic
Machinery murmur that is continuous and maximal at 2nd intercostal space, bounding peripheral pulses, wide pulse pressure
Tx: Medical management ie Indomethacin in preemies, cardiac cath in full term infants, may require surgical correction
Rutgers PANCE/PANRE Review Course
Coarctation of the Aorta Narrowing of the aortic lumen
More common in males
Sx: CHF, HTN
Dx: 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 axilla
X-ray: notching of the ribs in older kids
Tx: Surgical correction
Rutgers PANCE/PANRE Review Course
Cyanotic Lesions
Tetralogy of Fallot VSD
Pulmonary stenosis
Overriding Aorta
RVH
Tricuspid Atresia
Transposition of the Great Vessels
Total Anomalouus Pulmonary Venous Return
Truncus Arteriosus
Rutgers PANCE/PANRE Review Course
Tetralogy of Fallot Most common type of cyanotic heart lesion
4 components: VSD, pulmonary stenosis, overriding aorta, right ventricular hypertrophy
sudden cyanosis, dyspnea on exertion - hypoxemic spells aka “tet spells”
rough, systolic ejection murmur 3rd intercostal space
X-ray: Boot shaped heart
Tx: Medical then surgical by 18 months
Rutgers PANCE/PANRE Review Course
Courtesy of Wikipedia Rutgers PANCE/PANRE Review Course
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 nl inspiratory views, but exp views show localized hyperinflation, with mediastinal shift to the left. Which of the following is the most likely diagnosis?
Rutgers PANCE/PANRE Review Course
Ast
hma
Epig
lotti
tis
Fore
ign b
ody asp
iratio
n
Pulm
onary e
mbolis
m
Vira
l pneum
nia
0% 0% 0%2%
98%
1. Asthma
2. Epiglottitis
3. Foreign body aspiration
4. Pulmonary embolism
5. Viral pneumnia
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:
Rutgers PANCE/PANRE Review Course Heart
failu
re
Bro
nchio
litis
Cro
up
Epig
lotti
tis
Pneum
onia
0%
93%
7%0%0%
1. Heart failure
2. Bronchiolitis
3. Croup
4. Epiglottitis
5. Pneumonia
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?
Rutgers PANCE/PANRE Review Course
Rect
al bio
psy
Chest
X-ra
y
Urin
e glu
cose
assess
ment
Urin
e pro
tein
asse
ssm
ent
Sweat t
est
0% 0%
100%
0%0%
1. Rectal biopsy
2. Chest X-ray
3. Urine glucose assessment
4. Urine protein assessment
5. Sweat test
Which of the following congenital heart defects is associated with cyanosis?
Rutgers PANCE/PANRE Review Course
Pate
nt duct
us arte
riosu
s
Atr
ial se
ptal d
efect
Ventri
cula
r septa
l defe
ct
Coarc
tatio
n of t
he aort
a
Tetra
logy o
f Fallo
t
0% 0%
98%
0%2%
1. Patent ductus arteriosus
2. Atrial septal defect
3. Ventricular septal defect
4. Coarctation of the aorta
5. Tetralogy of Fallot
Gastrointestinal/Nutrition
Pyloric Stenosis
Intussusception
PKU
GI foreign bodies
Rutgers PANCE/PANRE Review Course
PYLORIC STENOSIS
Hypertrophy of muscular layers of pylorus leading to obstruction,
Begins between ages 2-4 weeks. Rare at birth or over the age of 6 months
Much more common in males
Classic presentation “Projectile, non-bilious vomiting and palpable pyloric mass or “olive”. Well, hungry child
Dx: Physical exam, ultrasound.
Tx: Surgery Rutgers PANCE/PANRE Review Course
INTUSSUSCEPTION
Invagination of part of the bowel into an adjacent part of the bowel
Most cases idiopathic; males>females
Most common from 6-12 months of age
Sx: Paroxysmal abdominal pain is main symptom, followed by vomiting and diarrhea
“Currant-jelly” stool in 50% of cases
Exam: Sausage-shaped mass
Tx: Reduction (Barium enema) and/or open surgery
Rutgers PANCE/PANRE Review Course
PKU
Cause: Dec activity of phenylalanine hydroxylase (enzyme that converts phenylalanine to tyrosine)
S&S: severe mental retardation, hyperactivity, seizures, light complexion, urine w/mouse-like odor
Dx: Increased phenylalanine, Decreased tyrosine
Tx: Limit dietary phenylalanine
Rutgers PANCE/PANRE Review Course
GI FOREIGN BODIES
Coins, toys, and batteries are most common
Upper esophagus - remove to lower risk of aspiration (Foley catheters often used)
Lower esophagus - remove if > 24 hours
Stomach - < 3-5 cm usually pass GI tract
If object is sharp or caustic (open safety pin, camera batteries) - endoscopy.
If toxic (medication tablets) - lavage
Rutgers PANCE/PANRE Review Course
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:
Rutgers PANCE/PANRE Review Course A
dmiss
ion fo
r surg
ical e
x...
Rem
oval of t
ab by e
ndo...
Extra
ct w
ith Fogarty
cat..
.
Gast
rogaf
in sw
allow
to r.
.
Obse
rvatio
n of t
he pat
ie...
2%
83%
11%
0%4%
1. Admission for surgical extraction
2. Removal of tab by endoscopy
3. Extract with Fogarty catheter
4. Gastrogafin swallow to r/o esophageal injury
5. Observation of the patient’s stool for passage of tab
Which of the following findings is most suggestive of a diagnosis of pyloric stenosis in an infant?
Rutgers PANCE/PANRE Review Course
Epig
astri
c mass
Failu
re to
thriv
e
Pro
ject
ile vom
iting
Abdom
inal
distentio
n
43%
0%
57%
0%
1. Epigastric mass
2. Failure to thrive
3. Projectile vomiting
4. Abdominal distention
Orthopedics
Classification of fractures
Congenital Hip Dysplasia
SCFE
Osgood-Schlatter
Nursemaid’s Elbow
Rutgers PANCE/PANRE Review Course
Salter-Harris Classification Type I - Epiphyseal separation through the physis
Type II - Fracture through a portion of the physis but exiting across the metaphysis
Type III - Fracture through the physis but exiting across the epiphysis into the joint
Type IV - Fracture through metaphysis, physis, and epiphysis
Crush injury to the physis
Rutgers PANCE/PANRE Review Course
Reproduced with permission of author, Dr Frank Gaillard
S
A
L T R
Rutgers PANCE/PANRE Review Course
CONGENITAL HIP DYSPLASIA (Developmental Dislocation of the Hip)
Increased risk in first-born females, breech birth, or family history of DDH
Dx: Screening exam essential at each visit
Ortolani (Out) test - Abduct/external rotation Palpable click as dislocation reduced
Barlow test: Adduct/Internal rotation Palpable click as hip dislocates
Physical Exam: Assymetric thigh folds
Ultrasound under 3 months. X-rays if older
Tx: Harness. Surgery
Complications: (untreated) Limp, pain, degenerative disease of hip Above image courtesy of wikipedia
Rutgers PANCE/PANRE Review Course
SCFE: Slipped Capital Femoral Epiphysis
Femoral head “slips” - exposing the anterior and superior aspects of the femoral neck
Males (14-16 yrs) > Females (11-13 yrs)
Associated with obesity, increased height, genital underdevelopment, pituitary tumors
Sx: Acute or chronic hip or knee pain
X-ray pearl: Ice cream falling off the cone
Tx: Surgery Above image courtesy of www.expertconsult.com Rutgers PANCE/PANRE Review Course
OSGOOD-SCHLATTER SYNDROME
Fibrocartilage microfracture of the patellar ligament
Most common in adolescent males
Activity related pain lasts 12-24 hrs
Tenderness, thickening at tibial tubercle
X-rays: Prominent, irregular. Fx?
Tx: Rest, ice, compression, NSAIDS
Rutgers PANCE/PANRE Review Course
NURSEMAID’S ELBOW Subluxation of the Radial Head
Occurs after forearm or wrist is jerked with longitudinal/pronational forces (“airplane”)
Common presentation: Child holds arm in
pronated and flexed position and resists
extension
Dx: History, exam. Radiographs are normal
Tx: Reduction by supinating/extending arm. Splint if recurrent. Prevention
Above image courtesy of wikepedia Rutgers PANCE/PANRE Review Course
Skin
Measles
Mumps
Rubella
Varicella
Roseola
Erythema infectiosum
Hand-foot-mouth disease
Kawasaki syndrome
Review Immunization schedule
Rutgers PANCE/PANRE Review Course
Measles: Rubeola
Morbillivirus in the Paramyxovirus family
Rare at any age
Incubation: 8-12 days for sx, 14 days for rash
Prodrome: fever (101+), cough, coryza, conjunctivitis Koplik spots
Rash: Neck & Abdomen first - maculopapular
Tx: Primarily supportive
Rutgers PANCE/PANRE Review Course
Courtesy of Centers for Disease Control and Prevention
Rutgers PANCE/PANRE Review Course
“Mumps: “Parotitis” Paramyxovirus
Incubation 12-25 days
Late winter & spring
Pain & swelling in front of and below ear
Often testicular pain within 1 week
Complete recovery with supportive care in 1-2 weeks is the rule
Image above courtesy of Centers for Disease Control and Prevention
Rutgers PANCE/PANRE Review Course
Rubella: “German measles
Rubella virus is a togavirus; Rubivirus
Rare at any age
Congenital rubella is deadly, especially in the first trimester, TRIAD: deafness, cataracts, cardiac defects
Description: Blueberry muffin baby
Acquired: Erythematous rash progressing from head to toes
PREVENTION!
Courtesy of wikepedia
Rutgers PANCE/PANRE Review Course
Varicella: “Chicken Pox”
Varicella-zoster virus
Usually 5 to 9 yrs old
Late winter/early spring
Incubation: 10-21 days
Vesicular, erythematous rash on torso, then face and extremities
Description: “Dew drops on a rose petal”
Tx is supportive
Rutgers PANCE/PANRE Review Course
Courtesy of Centers for Disease Control and Prevention
Rutgers PANCE/PANRE Review Course
Rutgers PANCE/PANRE Review Course
Courtesy of Centers for Disease Control and Prevention
Roseola: “Roseola infantum”
HHV-6
Ages 3 months - 4 years
Incubation 5-15 days
Maculopapular rash
High fever (102-105) for 3-5 days
Fever starts resolving, THEN rash appears
Tx is supportive
Rutgers PANCE/PANRE Review Course
Erythema infectiosum: “Fifth Disease” or “Slapped Cheek Syndrome
Parvovirus
School aged children
Incubation 4-14 days
Red facial rash and lacy, pink macular rash on torso & extremities
Pregnant woman at risk: hydrops fetalis
Tx is supportive
Rutgers PANCE/PANRE Review Course
Courtesy of Wikepedia
Rutgers PANCE/PANRE Review Course
Courtesy of wikepedia Rutgers PANCE/PANRE Review Course
Hand-Foot-and-Mouth Disease Coxsackie A16 virus (most common)
Under 5 years
Incubation 3 - 7 days
Late summer & fall
Painful oral ulcers, low grade fever, gray-red vesicles on hands and feet
Tx is supportive
DDx: Herpangina/Gingivostomatitis
Rutgers PANCE/PANRE Review Course
Courtesy of Dr. William Sears, www.askdrsears.com Rutgers PANCE/PANRE Review Course
Courtesy of Dr. William Sears, www.askdrsears.com
Rutgers PANCE/PANRE Review Course
Courtesy of Dr. William Sears, www.askdrsears.com Rutgers PANCE/PANRE Review Course
Kawasaki Syndrome/Disease “Mucocutaneous Lymph Node Syndrome
Etiology unknown - infectious agent likely
Under 5 years old
Fever > 5 days AND four of the following: conjunctivitis, rash, mucosal changes, edema of hands/feet, cervical adenopathy > 1.5 cm
Complications: anuerysms
Tx: IVIG, Aspirin
Rutgers PANCE/PANRE Review Course
Recommended Childhood Immunization
Schedule, United States
Rotavirus
Hepatitis A
Varicella
Pertussis
Meningococcal
Human papilloma virus
Rutgers PANCE/PANRE Review Course
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?
Chore
a
Congest
ive h
ea...
Coro
nary arte
r...
Mese
nteric
art...
Valvu
lar h
eart...
5%0%
5%0%
91%1. Chorea
2. Congestive heart failure
3. Coronary artery aneurysm
4. Mesenteric arteritis
5. Valvular heart disease
Rutgers PANCE/PANRE Review Course
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?
CT sc
an
Elect
roence
pha...
Lum
bar p
unctur..
.
MRI s
can
Mye
logr
aphy
30%
9%
0%2%
59%
1. CT scan
2. Electroencephalography
3. Lumbar puncture
4. MRI scan
5. Myelography
Rutgers PANCE/PANRE Review Course
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?
Adm
inist
ratio
n of s
yrup ..
Bar
ium
swall
ow x-
ray st
udy
Chest
physic
al thera
py
Esophag
ogast
roduoden...
Inse
rtion o
f a n
asogast
ri...
5%
20%
8%
68%
0%
1. Administration of syrup of ipecac
2. Barium swallow x-ray study
3. Chest physical therapy
4. Esophagogastroduodenoscopy
5. Insertion of a nasogastric tube
Rutgers PANCE/PANRE Review Course
Rutgers PANCE/PANRE Review Course