Peds Review (1)

8/12/2019 Peds Review (1)

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Pediatric Review

Richard Arias, MPAS, PA-C, DFAAPA

June 2014


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Pulmonary Medicine

Bronchiolitis

Cystic Fibrosis

Pneumonia

Tb


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Bronchiolitis

An obstructive pulmonary disease

Attacks infants and young children

Most often caused by RSV infection

Smoking household/crowed conditionsincreases occurrence

Is a clinical diagnosis: prodrome followedby cough, nasal flaring, lethargy, andtachypnea


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Cystic Fibrosis

Most common autosomal recessive illness

Genetic based protein deficit

Predominantly in White Europeans

Manifests in first year

Impact on respiratory tract

90% have pancreatic insuffiencyMedian survival 30 years of age

Persistent pulmonary infections


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Pneumonia

Infection of inflammation of the lung

parenchyma

Most episodes in young children result

from viral infection

A smaller percentage results from bacterial

infection


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Pathophysiology

Organisms that cause viral pneumonia are

also common causes of viral URI

Bacterial causes vary with age of the child

Intracellular organisms such as Chlamydia

trachomatis, M. pneumoniae, cause lower

respiratory tract disease


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Signs & Symptoms

Viral

Prodrome

progresses toSOB,course rhonchi,

nasal flaring,

tachypnea, wheezing

normal or slightly inc.

WBC

Bacterial

acute onset

toxic appearance

pleuritic chest pain,

chills, high fever, fine

rales, poor feedingelevated WBCS with

PMNS


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CXR

Viral

Patchy broncho-

pneumonia

Bacterial

Consolidation, plural

effusion


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Pneumonia Types

Group Bstrepleading cause ofpneumonia in neonates

Chlalmydia trachomatis is a common causeamong young infants, 2-3mo

Pneumococcus is the most common cause

of bacterial pneumoniaAtypical pneumoniaMycoplasm and

chlamydia pneumonia


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Laboratory Evaluation

Diagnostic Laboratory workup for childrenis extensive

WBC counts are typically high, withpredominance of PMNs in bacterialPneumonia

Typical chest radiographic findings forviral, Mycoplasma, and bacterialpneumonia are distinctive


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Management

Antimicrobial treatment of bacterial

pneumonia is appropriate

Outpatient management is sufficient

Close observation is necessary until

children improve

Decisions regarding hospitalization are

base on severity of sxms


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Complications

Pleural effusion

Empyema

Lung abscess

Bronchiectasis


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Prognosis


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Tuberculosis


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Etiology

Due to infection by Mycobacterium

tuberculosis, an acid-fast bacillus

Majority of infected persons so not developactive disease

Transmitted from person to person via

respiratory droplets

Highly contagious and difficult to diagnose


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Epidemiology

One of the most common worldwide

causes of infection-related death

In infected, immunocompetent patients, thelifetime risk of developing desease is


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Diagnosis

PPD reaction after 24-48 hours

- 15mm induration is a positive test

PPD reaction positiveobtain CXR

TB exposure: PPD is neg. and cxr is neg.TB infection: PPD is pos. but cxr is neg.

TB disease: PPD and CXR are positive


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Treatment

TB infection

- INH prophylaxis for 9 months

- Administer vit. B6 to adolescents and

adults to prevent INH-induced neuropathy


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Treatment

TB disease

- begin therapy with INH, rifampin,and

pyrazinamide- Adjust therapy according to drug susceptibility of

isolates from sputum or gastric aspiratespecimens

- Usual duration of RX is 6mo or until repeatspecimens are negative

- Direct-observed therapy by healthcare worker toensue compliance


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Prognosis/Clinical Course

Treatment is complicated by the need for

multiple drugs over a prolonged time

Strict infection-control measures arenecessary

Up to 3 million deaths occur annually

worldwide


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Pediatric Cardiology

Aortic stenosis

Pulmonic stenosis

Aortic coarctation

Left to right shunt lesions


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Aortic Stenosis

5% of all CHD M:F = 4-1

Most asymptomatic

Chest pain, CHF is severeUsually progressive

PE: normal BP, narrow pulse pressure in

severe AS, ejecton click, 2-4/6 harsh SEM@RU SB/LUSB w/radiation to neck

EKG and CXR normal in most cases


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Pulmonic Stenosis

5-8% of Congenital heart ds

Symptoms vary depending on severity of

the stenosis

Systolic murmur with ejection click

,


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Coarctation of the Aorta

8-10% of all congenital heart disease

Incidence of 3.2/10,000 live births

2:1 male to female predominance

85% also have a bicuspid aortic valve

May be associated with Turner syndrome


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Signs/Symptoms

Symptomatic neonates exhibit evidence of

CHF/cardiogenic shock

Typically have a gallop rhythm

Differential strength of pulses is less

obvious until CHF/shock is treated


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Diagnosis

Fourextremity blood Pressures

EKG:right ventricular hypertrophy in

neonates ; left ventricular hypertrophy inolder child/adolescents

CXR: Variable

Echocardiography (with Doppler) is

diagnostic


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Treatment

Surgical Repair

Neonates with CHF/cardiogenic shock

should be treated medically prior tosurgical repair

Balloon angioplasty

Lifelong bacterial endocarditis prophylaxis

is beneficial


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Left to Right Shunts Lesions

ASD

VSD

PDA


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ASD

Shunting of fully oxygenated blood back

into the lung

Fixed widely split S2

SEM @ LUSB

EKG usually normal

CXR: cardiomegaly, increased pulmonary

markings


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PDA

Bounding pulses

Continuous murmur @ LUSB and

subclavicular area

EKG: normal or LVH

CXR: large LA/LV


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Pediactric GI Illnesses

Pyloric Stenosis

Intusussception

Hirschprungs

Meckels

Anal fissures

Henoch-Schonlein purpura


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Pyloric Stenosis

M>F, spring births

projectile vomiting

palpable abd mass

Rx: surgical release of pylorus

DD: formula intolerance


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Intusussception

Most occur in children < 1 year old

intermittent colicky abdominal pain

vomiting (80%0

currant jelly stool (95% of infants/65% of olderchildren)

sausage shaped mass in abdomen (85%)

Dx& Rx:Sonogram / instillation of contrastagents, saline, or air

failure needs surgery


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Hirschprungs

Congenital aganglionic megacolon

assoc w/ Downs and other congenital

anomaliesM:F=4:1 newborn DX: failure to pass meconium in first 48 hours

followed by abd distention & bilious vomiting. Cause of40-50% of newborn intestinal obstruction

older children: chronic constipation

urge to deficate is rare b/c stools are retained proximal tothe anorectum

DX: absence of plexus ganglion on pathology


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Meckels

Blind omphalomesenteric duct causing an

antimesenteric outpouching of ileum

2:1 male predominancemost are asymptomatic

S&S: painless rectal bleeding, intestinal

obstruction, pain mimicking appendicitis

RX: wide wedge resection of diverticulum


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Henoch - Schonlein Purpura

Most common vasculitis in children

immunoglobulin IgA mediated

etiology unknown

purpuritic rash on lower extremities and

buttocks

abdominal pain most common complaint


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7/23/2014

Pediatric ID

Meningitis

Rubeola

Rubella

Varicella

Roseola Infantum

Fifths Disease

Herpes Simplex


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contd

Scarlet Fever

Kawasaki

Lyme

Steven Johnson Syndrome

Epiglottitis

Laryngeotracheobronchitis

Pertussis

Fever Without Source

Fever of Unknown Origin


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Meningitis

Bacterial meningitis is especially commonin winter

70% of cases occur in children


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RX:

Hospitalize

Isolate

Bacterial: Third-generation cephalosporin

plus vancomycin

antipyretic

follow-up: hearing, cognitive,

neuromuscular function


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Rubeola (Measles)

Paramyxovirus

winter & spring

spread via droplets

incubation 9-14 days

contagious 7 days after exposure and 5

days after cough

KOPLIK SPOTS


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FOUR Cs

COUGH

CORYZA

CONJUNCTIVITIS / PHOTOPHOBIA

CONFLUENT MACULOPAPULAR

RASH starts centrally & spreads peripherally


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Treatment

Supportive

passive immunoglobulin for

immunocompromisedacute exposure vaccinate within 3

days/after 3 days give gammaglobulin

PREVENTION BY VACCINATIONComplications:pnuemonia, otitis,

encephalitis, myocarditis


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Rubella (German Measles)

Rubivirus


no prodromemild coryza, fever conjunctivitis without photophobia

suboccipital and postauricular adenopathy

Forschmyer spots on palate maculopapular rash central to periphery


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Recurs as herpes zoster

See giant cell on microscopy of vesicle

Rx: supportive Caladryl

prevent scratching

avoid ASA

Vidarabine for varicella pneumonia

IV Acyclovir for pneumonia inimmunocompromised patients


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Roseola Infantum

Herpes 6

6-18 months old

incubation 7-14 days/ spring & fall

S & S-high fever w/ or w/out febrile seizure forthree days followed by exanthem

edema of eyelids or exudative tonsillitis

Rx: supportive PCN for + throat culture

seizure prevention

Fif h Di


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Fifths Disease

(Erythema Infectiosum)

Parovirus

preschool-school aged children


S & S nonspecific febrile illness x 1-2 daysfollowed 5-6 days later with a slapped cheekappearance

Rx: supportiveComplications:arthritis,hemolytic anemia,

encephalopathy, pneumonitis


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Scarlet Fever

Staph-no exanthem

Strep-no exanthem

incubation 1-7 days

S & S: days 1-2: fever, sore throat, sandpaper rash

days 2-3: white strawberry tongue

days 5-6; strawberry red tongue, petechial lesions

on pharynx 7 tonsils


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Rx: PCN

Complications: sinusitis, mastoiditis,

cervical adenitis, osteomyelitis, rheumaticfever, glomerulonephritis.


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Kawasaki

Occurs sporadically or in epidemics

etiology unknown

S & S: irritability, altered mental status, cough,vomiting, diarrhea, abd pain, fever, bilateral

conjunctivitis

*****cardiac manifestations

10-40 % coronary vasculitis--dilated or aneurysmal arteries


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Diagnostic Criteria

Fever lasting at least five days

4 of 5 of the following:

bilateral nonpurulent conjunctival injection

oropharyngeal mucosa changes-infected pharynx,

infected lips, strawberry tongue

changes of peripheral extremities-edema/erythema of

hands or feet,desquamation

rash-truncal/nonvesicular

cervical lymphadenopathy


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Rx: IV human gamma globulin in early

active febrile disease prevents cardiac

complicationssurgery for cardiac stenotic lesions

heparin for anuerysms


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Lyme

Deer tick borne by spirochete Borrelia

burgdorferi

Stage 1: localized erythema migrans, migratorymusculoskeletal pains

Stage 2: disseminated disease in un Rx pts

causing CNS, CV and MS system involvement

Stage 3: persistent infection causing progressive

arthritis, depression , intellectual impairment


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Rx: Stage 1: ampicillin or Doxy

Stage 2: Ceftriaxone (crosses BBB)

Stage 3: Amp/PCN, Ceftriaxone

PREVENT TICK BITES


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Epiglottis

H. flu type B, Strep group B, Staph

2-7 yo, all year long, rare recurrence

S & S: fever, sore throat, dyspnea, resp.distress, prostration, dysphagia, drooling,stridor, brassy cough, toxic

Soft tissue neck x-ray: thumb signRx: oxygen, IV abx (2nd -3rd generation

cephalosporin), protect airway


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Laryngotracheobronchitis

Parainfluenzae type 1 & 3

most common viral form of croup

8 months - 5 years old, wintertime

S & S: prodromal URI, inspiratory stridor,

barking cough,

CXR: steeple sign

Rx: steam, cool mist,


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Pertussis

Bordatella pertussis

3 stages:

1. Catarrhal 1-2 weeks rhinorrhea, mild cough, lowgrade fever .

2. Paroxysmal 2-4 weeks forceful cough,

inspiratory whoop, facial redness, bulging eyes,

lacrimation, vomiting 3. Convalescence decreased cough & vomiting


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CXR: perihilar infiltrate

Rx: erythro

prevention by vaccination

Complications: pneumonia, otitis, epistaxis ruptured diapraghm


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Fever Without Source

Pts with fever>100.4, but the source offever is not obvious

20% of childhood fevers have no apparentcause

Commonly seen in children between 1moand 3yrs

Children


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Fever of Unknown Origin

Defined as a prolonged fever >21 days

An explanation for the fever is eventually

found in 90% of casesInfections account for 1/3 of cases

Some patients never have a final DX

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