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USMLE2 Pediatrics 01

QuestionAnswer
Differential for salmon colored rash 1. Typhoid fever, 2. juvenile rheumatoid arthritis, 3. Adult Stills (rheumatoid arthritis)
Diagnosis of SLE MD SOAP N HAIR. Malar rash, Discoid rash, Serositis, Oral ulcers, Arthritis, Photosensitivity, Neuro disorders (sz's), Heme disorders (anemia), ANA Ab, Immune (anti-dsDNA - sensitive and follows dz activity, anti-Smith - sensitive), Renal (nephrotic)
Diagnosis criteria for juvenile rheumatoid arthritis 1. onset <16yo, 2. arthritis >1 joint, 3. duration >= 6 wks, 4. exclusion of other arthritis
How does juvenile rheumatoid arthritis present? 1. morning stiffness, 2. easy fatigue, 3. as day progresses, increased joint swelling, warmth, and decreased motion with increased pain (no redness)
Diagnosis criteria for Kawasaki disease Vasculitis of medium and coronary vessels. Fever for >= 5days AND 4 of the following: 1. BL conjunctivitis, 2. strawberry tongue/cracked lips, 3. hands and feet - eryth, swelling, desquamation, 4. rash, 5. cervical LAD
Encapsulated Bacteria Some Killers Have Pretty Nice Big Capsules: S. PNA, Salmonella, Klebsiella, Hflu, Pseudomonas, Neisseria mening, GBS, Cryptococcus
In a child with fever without a focus, who should get empiric abx? Rectal T > 38C (100.4F) OR [ CBC > 15,000 and >1500 Bands ]
Definition of fever without a focus fever >38C for < 1 week in child < 3yo
How to manage a neonate (<28d) with fever without a focus Admit to hospital for Cx and prophylactic abx - covering for BEL (GBS, E.coli, Listeria)
In an infant (1mo to 3 months old), what is the most common organism causing fever without a focus? Strep PNA
In an infant (1 mo to 3 months old), what is the workup for fever without a focus if the child appears well? 1. Cx, 2. IM CTX x1, 3. CXR, 4. fu in 24h
In an infant (1mo to 3 months old), what is the workup for fever without a focus if the child appears toxic? 1. Admit to hospital, 2. obtain Cx, 3. empiric IV abx with vanc and CTX
In an infant/toddler (>3mo to 3yo), what is the workup for fever without a focus if the child appears toxic? 1. Admit to hospital, 2. obtain Cx, 3. empiric IV abx with vanc and CTX
In an infant/toddler (>3mo to 3yo), what is the workup for fever without a focus if the child appears healthy AND T<39C/102.2F? no wu indicated
In an infant/toddler (>3mo to 3yo), what is the workup for fever without a focus if the child appears NOT toxic AND T>39C/102.2F? 1. Cx (UCx+UA, Stool Cx, BloodCx if WBC>15K), 2. IM CTX x1, 3. CXR, 4. fu in 24h
Definition of fever of unknown origin T>38C/100.4 AND no origin found after [3wk outpt wu OR 1wk inpt wu]
In an infant/toddler (>3mo to 3yo), fever without a focus, child is NOT toxic AND T>39C/102.2F. You've started empiric abx. W/u shows +UCx, but child is afeb. What should you do? Give outpt abx.
In an infant/toddler (>3mo to 3yo), fever without a focus, child is NOT toxic AND T>39C/102.2F. You've started empiric abx. W/u shows +BCx with S.PNA, child is afeb and well appearing. What should you do? Repeat BCx. Consider LP.
In an infant/toddler (>3mo to 3yo), fever without a focus, child is NOT toxic AND T>39C/102.2F. You've started empiric abx. W/u shows +BCx and child has persistent fever. What should you do? Admit.
In an infant/toddler (>3mo to 3yo), fever without a focus, child is NOT toxic AND T>39C/102.2F. You've started empiric abx. W/u shows -BCx. What should you do? Careful obs and close f/u
In infant 0-2mo, what are the most likely organisms in bacterial meningitis? Baby BEL - GBS, E.coli, Listeria
In child 2mo to 12 yo, what are the most likely organism in bacterial meningitis? Strep PNA and N. meningitidis. HiB uncommon now due to immunizations.
Child coming in with bacterial meningitis - sudden or gradual onset more likely? Gradual more likely with several days of fever, lethargy, irritability, anorexia, nausea, and vomiting. Then meningeal irritation.
What are the clinical signs of meningeal irritation photophobia, neck and back pain, rigidity, Kernig sign (leg raise flexing at hip causes pain), brudzinski (invol flex knees and hip when passive neck flexion)
Signs of increased ICP HA, emesis, bulging anterior fontanelles, oculomotor or abducens palsy, HTN with bradycardia, apnea, decorticate or decerebrate, stupor, coma
What are the contraindications to an LP in diagnosing meningitis? 1. evidence of increased ICP, 2. severe cardiopulm prob requiring resuscitation, 3. infection over skin site, 4. bleeding diathesis (PT/PTT/INR) NOTE: if need CT before LP, DO NOT delay starting abx treatment. Start abx before CT.
For an infant, what is the empiric tx for bacterial meningitis? IV vanc + [cefotaxime OR CTX]
For an infant, what is the tx for bacterial meningitis if organism is S. PNA? PCN or CTX x 2 weeks
For an infant, what is the tx for bacterial meningitis if organism is N. meningitidis? PCN or CTX x 1 wk
For an infant, what is the tx for bacterial meningitis if organism is HiB? Ampicillin x 1 wk + initial IV dexamethasone (dec fever and 8th cranial nerve damage)
For an infant, what is the tx for bacterial meningitis if abx were started before cx and no org found on cx? CTX x 1 wk
For an infant, what is the tx for bacterial meningitis if organism is gram neg (i.e. E.coli)? CTX x 3 wks
What tx should family members of infants with meningitis get? If N. meningitidis or HiB, prophylax with rifampin. DO NOT prophylax if S.PNA. (all close contacts should be prophylaxed regardless of age or immune status)
Meningitis that has temporal lobe involvement (focal sz's, CT, MRI, EEG) should think HSV
What is the most common presentation of pt with VZV meningitis? cerebellar ataxia and acute encephalitis
What is the most common presentation of pt with CMV meningitis? someone who is immunocompromised has disseminated dz. can also be congenital. NOT in someone who is immunocompetent.
What is the most common presentation of pt with EBV meningitis? 8th nerve damage - hearing loss
What are common presenting signs of viral meningitis in older child? in infant? Older: HA and hyperesthesia. Infant: irritability and lethargy.
What are common presenting signs of viral meningitis? Fever, n v, photophobia, neck/leg/back pain, rash
What organisms cause rash in meningitis? purpuric - N mening; viral exanthems - echo or coxsackie; VZV, measles, rubella
What is best test to dx viral meningitis? PCR of CSF
3 phases of whooping cough 1. catarrhal (2 wks) - rhin, conj inj, cough, 2. paroxysmal (2-5wks) - coughing paroxysms and petechiae, 3. Convalescent (2wks) - gradual resolution of cough
How to dx whooping cough? nasopharyngeal cx
How to tx whooping cough? erythromycin x 2wks for pt AND close contacts
warthin-starry stain G- bacilli --> Bartonella (cat-scratch dz)
Lyme disease CRAB - Carditis, Rash, Arthritis, Bell's palsy
Tx for Lyme disease <8yo: amoxicillin. >8yo: Doxycycline x 2-3wks.
Tx for Lyme disease with meningitis or carditis CTX OR PCN x2-4 wks
Tx for Lyme disease with Bell's palsy Doxycycline OR amoxicillin x 3wks
Tx for late-diagnosed Lyme disease (has arthritis) Doxycycline OR amoxicillin x 4wks
deer tick on East Coast Lyme disease - Borrelia burgdorferi
ticks from Southeast US RMSF - rickettsia rickettsii
Triad of RMSF Hot Rocky Fever - 1. HA, 2. Rash (pale, rose colored, maculopapular, palms and soles), 3. Fever
Tx for RMSF Doxycycline OR Tetracycline in all pts
Tibial erythema nodosum Coccidioidomycosis
Disseminated Coccidioidomycoses FEM - 1. Flu-like sx's +/- CP, 2. Erythema nodosum on tibia, 3. Maculopapular Rash
Measels Triad CCC - Coryza (head cold), Cough, and Conjuntivitis
Koplik spots white gray dots on buccal mucosa - measels
paramyxovirus measels or mumps
Rubella triad LAR - 1. Lymphadenopathy (posterior cervical, occipital, auricular), 2. Arthritis (multiple joints), 3. Rash (starts on face, pinpoint, with rose spots on palate)
Forscheimer spots rose-colored spots on soft palate in rubella, appears before body rash
diseases that have rose-colored spots on soft palate MRS. Rose - Measels, Rubella, Scarlet fever
Roseola Triad FOR Rose. high Fever (3d) preceding rash, Occipital LAD, Rash (ROSE colored papules on trunk, arms, neck and face).
face with parotid swelling mumps
Rash in various stages of macules, papules, vesicles, pustules Varicella
Varicella triad PCR - Pruritis, Crops of lesions, Rash in various stages
Tzank prep showing multinucleated giant cells Herpes viruses: VZV, HSV
Fifth's Disease 5th graders have bad teeth. must become a flosser - FLASSA - Fetal hydrops, Lacy reticular rash on trunk and extremities, Arthritis, Spare palms and soles, Slapped cheeks, Aplastic crisis in pts with hemolytic anemia
Scarlet Fever PSPS: Pharyngitis, Sandpaper rash, Pastia lines (petechiae in skin creases), Strawberry tongue
Mono FLiP iT! Fatigue, LAD (esp cervical, epitrochlear - medial bicep), Pharyngitis, Tonsillar swelling)
Onset of rash after taking ampicillin or amoxicillin for URI sx's Mono - EBV
Diagnosis of EBV mono Monospot (heterophile antibody), WBC lymphocytosis, elevated LFT's. Gold standard is IgM to viral capsid antigen.
EBV associated with which cancers? Burkitt's lymphoma, Nasopharyngeal CA, Hodgkin's lymphoma (RS cells).
Created by: christinapham