Peds OSCE Pack

Nick Graham Nic Todd Zak Peters

Standard Pediatric History and Physical:

History: ID: age, sex, nationality, home, CC HPI: PMHx: PSHx: Pregnancy: prenatal care, U/S, complications (GDM, HTN, infections, rash, fever, bleeding), meds, smoking/EtOH/drugs, IUGR Delivery: gestation, G#P#, route of delivery, presentation, birth wt, apgars, complications (induction, bleeding), neonatal problems, NICU stay, LOS Nutrition: formula type, amount, frequency, solid foods, growth concerns Development: GM, FM, social, speech School Performance: grades, friends Immunizations: routine, special (HepA, PCV, Mengugate, VZV) FHx: genogram, pertinent familial diseases SHx: martial status of parents, family unit, finances, school/peer relations, HEADSS, health care plan, family support, effect of illness on family All: drugs, food, environmental Meds: drugs, supplements Physical: Appearance: dysmorphic feats, resp distress Vitals: T, HR, BP, RR, Sats, GCS Growth: wt, ht, HC H+N: dysmorphic feats, fontanelles, vision, red reflex, strabismus, hearing, MMM, TM, lymphadenopathy, neck mass, PERLA, conjunctiva, nasal secretions, nasal flaring, cyanosis, pharynx, palate CVS: S1/S2, S3/S4/ES/murmurs, PPPx4, cap refill, BP resp: AE, crackles/wheezes, tracheal tug, intercostal/subcostal indrawing, cyanosis, clubbing GI: BS, tenderness, masses, hernias, peritoneal signs, hepatomegaly, splenomegaly MSK: rashes, hips (Barlow, Ortolani), scoliosis, L-spine (hair, sinus tract, pigmentation) Neuro: CN exam, gait, limbs (power/tone/sensation/DTRs), coordination, primative reflexes Hydration: MMM, irritability, HR, BP, tearing, cap refill, skin turgor, sunken fontanelles Special Tests:

Anemia
Definition: Hb/Hct 2 SD below mean for age and sex History: ID: nationality (SEA thalassemia, African Sickle cell) HPI: duration, onset Anemia S/S: pallor, SOB, fatigue, syncope Nonspecific S/S: irritable, decreased PO intake, increased sleep, decreased exercise tolerance, HA Bleeding S/S: bruising, bleeding, epistaxsis, UGI bleeds (hematemesis, melena), LGI bleeds (hematechezia), menstuation Constitutional S/S: fever, wt loss, bone pain PMHx: transfusions, chronic disease, hypothyroidism PSHx: splenectomy Pregnancy: ABO/Rh, IUGR Delivery: gestational age, jaundice Nutrition: milk, # feeds, iron containing cereals Development: Immunizations: when, what, where FHx: nationality, anemia, transfusions, splenectomies SHx: lead paint in home All: Meds: sulfa drugs Physical: Appearance: pallor, jaundice, cyanosis Vitals: tachycardia, tachypnea Growth: dropping off if chronic H+N: conjunctiva (pallor/jaundice), lymphadenopathy (infiltrative disease) CVS: CHF, flow murmur, cap refill Resp: GI: hepatosplenomegaly (infiltrative disease) MSK: hands, nails, bruising/petechiae, edema Neuro: altered LOC Hydration: Special Tests: DRE, FOBT Investigations: CBC/d peripheral smear, retic count, hemoglobin electrophoresis serum Fe, TIBC, ferritin, iron sat Differential: Microcytic Fe deficiency, ACD, thalassemia, lead poisoning, sideroblastic anemia Normocytic Increased reticulocytes: bleeding, hemolysis (Sickle) Normal/Low reticulocytes: aplastic, malignancy, ACD, transient erythoroblastopenia of childhood, erythroid aplasia, bone marrow infiltration, ?sepsis Macrocytic B12/folate deficiency, liver disease, EtOH, hypothyroidism, aplastic, Fanconis anemia Treatment: Treat cause

 Ferrous sulfate 6mg/kg/day divided TID for 3 months side effects: stained teeth, dark stools, constipation

Asthma
General: Definition: IgE mediated reversible obstructive airway disease Spirometry only if greater than 6 years old History: ID: HPI:

Presentation: wheeze, cough, onset, duration, frequency Red Flags: fatigue, unable to speak full sentences Control: ER visits, admissions, intubations, night-time symptoms >1/wk, ventolin >3/wk, exercise limitation, many exacerbations, absenteeism Triggers: exercise, dust/pollen, URTI, stress/anxiety PMHx: eczema, allergic rhinitis, ASA sensitivity, nasal polyps PSHx: Pregnancy: Delivery: Nutrition: Development: Immunizations: FHx: asthma, eczema, allergic rhinitis SHx: environmental history All: environmental, dust, food Meds: B-agonists, oral/inhaled corticosteroids, anticholinergics, others

Physical: Appearance: level of comfort Vitals: decreased O2 sats, tachycardia, tachpnea Growth: H+N: CVS: pulsus paradoxus resp: cyanosis, pursed lip breathing, nasal flaring, tracheal/intercostal/subcostal indrawing, barrel chest, audible wheeze, AE, wheezes, crackles, percussion GI: MSK: Neuro: GCS Hydration: Special Tests: spirometry, PFTs Mild Asthma nighttime cough SOB w exercise + B-agonist use Moderate Asthma abbreviated speach SOB at rest ++ B-agonist use (>q4h) Severe Asthma altered LOC difficulty speaking laboured resps persistant tachycardia no relief w B-agonists

Near-Dea

Clinical Features

exhauste confused diaphore cyanotic apnea decrease effort failing he

O2 Sats PFTs (PEFR, FEV1) (as % of predicted/ personal best)

>95%

>92 - 95%

<92%

<90%

>75%

50 - 75%

<50%

inappropri

Treatment

B-agonists O2 systemic corticosteroids

B-agonists + O2 systemic corticosteroids anticholinergics

intubate B-agonists + O2 systemic corticosteroids anticholinergics methylxanthines

intubat B-agonis systemic corticost anticho methyl magne sulfate

Discharge: management plan (med use, avoidance of triggers) asthma teaching course of oral corticosteroids inhaled corticosteroids should be considered B-agonists anticholinergics

Asthma Environmental History

start with the bedroom and work outwards: Bedroom: bed, carpets, closet, windows/curtains, dust House: furniture, carpets, cleaning, toys, pets/plants, smoking, aerosolized chemicals, furnace/humidifier Location: city/farm Other: day care, sick contacts, hobbies/sports

Ambiguous Genitalia
4 possibilities: male pseudohermaphrodite (XY with palpable gonads) female pseudohermaphrodite (XX without palpable gonads) mixed gonadal dygenesis true hermaphrodite General hypospadias, undescended testicles, virilization of phallus and labioscrotal folds Physical

 palpate for gonads/testes normal 3.5cm, normal clitoris 1.5cm, microphallus <2cm Investigations: karyotype Adrenal steroids (17OH progesterone), electrolytes, U/S, MRI Differential male pseudohermaphrodite (XY, XO, XO/XY with palpable gonads) female pseudohermaphrodite (XX without palpable gonads) CAH (Tx - replacement of glucocorticoids and mineralocorticoids) mixed gonadal dysgenesis true hermaphrodite both male and female gonadal tissue present but may/not be functional (XX 80%)

Birth Control
History: ID: age HPI: PMHx: DM, SLE, liver disease, breast disease, migrane, bleeding/clots PSHx: GHx: menstrual Hx, abnormal bleeding, discharge, FHx: uterine/breast ca, clots, HTN/CVA/CAD SHx: smoke, drug use, sexual history (contraception) All: Meds: Physical: Breast: Pelvic: PAP and swabs Benefits: controlled cycle, bleeding/pain benign disease (breast, ovarian cysts) ca (ovarian/uterine) RA pregnancy/ectopic Risks: bleeding until correct dose clot STD if no other protection

Breast Feeding
General: how long: WHO recommends until 6 months how often: premature q2-3h, term q3.5-4h, q5h at night until 4.5kg or 2-3mo contents: 67kcal/100cc (40% carbs, 5% protein, 55% fat) supplements required: vit K, vit D, fluoride, iron Benefits: Allergic condiction reduced Best food for infant (nutrition + immunologic)

Close relationship with mother Devlopment of IQ, jaws, mouth Economical Fitness: quick return to pre-pregnancy body shape Guards against cancer: breast, ovary, uterus Hemorrhage (postpartum) reduced Risks: transfer disease (HIV) ?allergies from mom Contraindications: chemo or radioactive compounds HIV/AIDS, active untreated TB, herpes in the breast region heavy EtOH or illicit drug use meds (antimetabolites, bromocryptine, chloramphenicol, high dose diazepam, ergots, gold, metronidazole, tetracycline, lithim, cyclophosphamide) Not Contraindications: CMV hepatitis mastitis OCP Complications: sore/cracked nipples breast engorgement mastitis breast feeding jaundice breast mild jaundice poor weight gain oral candidiasis

Bowel Obstruction
History: ID: HPI:

Nausea/Vomiting: onset, frequency, amount, colour, relation to feeds, blood Pyloric Stenosis = projectile, non-bilious, early infancy, after feeds, maybe small amt blood Obstruction distal to ampulla = bilious, non-projectile (mid-gut vovulus, duodenal stenosis, duodenal/jejunal/ileal/ colonic atresia, meconium ileus, Hirschsprung's, imperforate anus) PUD = large hematemesis Abdominal Pain: OPQRST Obstipation: Alternating diarrhea and constipation: suggests intermittant obstruction (Hirschsprung's, intussusception, intermittent volvulus) Lower GI Bleed: melena, BRBPR, UGI bleed PMHx: PSHx: Pregnancy: Delivery: Nutrition:

Development: Immunizations: FHx: SHx: All: Meds:

Physical: Appearance: guarding Vitals: tachycardia, tachypnea, fever, hypoTN Growth: H+N: CVS: resp: GI: Inspection: shape, masses, hernias Auscultation: BSx4 (high-pitched) Palpation: x4, masses, multiple doughy masses (meconium ileus), tender non-mobile mass (abscess), hernias, organomegally, "Olive sign" Percussion: peritoneal signs MSK: Neuro: Hydration: Special Tests: rectal exam (imperforate, masses, blood)

Circumcision
Benefits: UTI, penile ca, STD, balanitis, prepuce problems Risks: bleeding, infection, trauma/scar, necrosis, anesthetic reaction, death Indications: phymosis, paraphymosis, balanitis, cultural/religious, cosmetic Contraindications: coagulopathy, hypospadias, penile abnormalities, comorbidities Care of newborn penis: clean w soap + water, do not retract foreskin (increased risk of phy/paraphymosis) Foreskin should be retractable by 5yrs

CXR Interpretation
Quality of film: Identification, view, inspiration (8-9 posterior views), rotation (clavicles), penetration (spinous processes) Hardware Soft tissue subcutaneous emphysema, swelling Bones clavicle, ribs Organs liver on R, gastric bubble on L, free air Lungs o Markings extend to edge o Costophrenic angles o Cardiac size o Describe markings coarse/reticular/ground glass, diffuse/patchy, symmetrical/

not o Fissures Findings o Bronchiolitis hyperinflation (flattened diaphragms, pneumothorax, pneumomediastinum, increased AP diameter), increased bronchovascular markings, atalectasis, interstitial infiltrates o Asthma hyperinflation, increased lung markings, atalectasis, peribronchial cuffing, pneumothorax, lobar collapse o Pneumonia lobar (consolidation in single lobe with air bronchograms), bronchopneumonia (diffuse streaky infiltrates) o Foreign body inspiration/expiration views (hyperinflation on expiration), Right mainstem bronchus o Transient tachypnea of the newborn (TTN) fluid in fissures, cardiomyopathy, increased vascular markings o Meconium aspiration coarse, patchy, asymmetric, air trapping o Hyaline membrane disease diffuse, ground glass, symmetrical

Child Abuse
Risk Factors: parents abused premartital conception young marriage unwanted pregnancy isolation marital disharmony financial problems EtOH, drug use child handicapped long separation from parents History: story doesn't fit trips to different ERs stories don't fit delay in presentation poor parent child interaction Physical: bruises: location: upper arms, trunk, anterior legs, sides of face, ears and neck, genitalia, buttocks pattern: bite, belt, rope, cord, slap, tied, gagged burns: location: buttocks, perineum, genitalia, ankles, wrists, palms, soles pattern: submersion burns, cirgarette burns head injuries: pattern: retinal hemorrhages eye injuries: pattern: bilateral periorbital hematoma, hyphema, retinal hemorrhages internal injuries: pattern: tears, ruptures, hematoma

 skeletal injuries: locations: posterior rib, scapula, patterns: epiphyseal/metaphyseal injury, #s in different stages of healing Management: proper documentation proper imaging alert CAPS SW consult

Child Safety
Falls Burns Poisoning Drowning/Suffocating Car Safety

Croup
Definition: viral infection causing subglottic and tracheal swelling Epidemiology: 6mos-3yr, parinflueza, influenza HPI: OPQRST barking cough, URTI, low grade fever, FB Physical: o General: decreased LOC, tachycardia, tachypnea, cyanosis o Resp: stridor, decreased ae, increased WOB (tracheal tug) dDx: Epiglottitis EMERGENCY, larygomalacia/tracheomalacia Treatment: 95% no admission (3-7d), Repiratory isolation, IV hydration, humidified/cool air, oxygen, Racemic epinephrine (decreases airway swelling), corticosteroids (dexamethasone), intubation

Dehydration
Definition: mild (5%), moderate (10%), severe (15%) History: ID: HPI: OPQRST, lethargy, irritable, emesis, diarrhea PMHx: PSHx: Pregnancy: Delivery: Nutrition: quantify U/O, BM, wt loss Development: Immunizations: FHx: SHx: All:

 Meds: Physical: Appearance: decreased LOC Vitals: tachycardic, hypotension Growth: H+N: sunken ant fontanelle, dry MM CVS: cap refill >3sec Resp: GI: MSK: Neuro: Hydration: Special Tests: Differential: Treatment: Bolus 10-20 mL/kg NS/RL, repeat until hemodynamically stable Replace 1/2 total deficit over 1st 8hr, 1/2 over next 16hr, add maintenance (421 rule) D5NS+20mEq KCl

Developmental Milestones:

Age (mo) 1 2

FM grasp reflex follows w eyes past midline

Language facial response to sounds coos

GM lifts head in prone position

Social stares at face

lifts head in smiles in prone position to response to 45o others sits: head steady, turns toward voice sits independently, stands w help pulls to stand stands independently, walks, one hand held walks independently smiles spont, rolls to supine reaches for toys, recognizes strangers feeds self, waves bye-bye points to indicate wants drinks from cup, imitates activities

hands open, laughs/squeals objects to mouth palmar grasp babbles "mama, dada", comprehends "no"

pincer grasp

12 (1)

2-4 words, helps turn pages follows of book command w gesture scribbles 4-6 words, follows command

15

18 (1.5)

turns pages of book solves single-piece puzzles imitates horizontal and vertical lines copies circle, draws person w 3 parts copies cross

10-20 words, points to 4 body parts combines 2-3 words, uses "I" and "you" names all body parts gives full name/ age/sex, names 2 colors understands "cold", "tired", "hungry"

walks up steps

feeds self w spoon removes coat, verbalizes wants pulls up pants, washes, dries hands toilet trained, puts on shirt, knows front from back associate play

24 (2)

jumps, kicks ball

30 (2.5)

rides tricycle throws ball overhand, walks up stairs stands on one foot for 2-3 sec

36 (3)

42 (3.5)

48 (4)

counts 4 objects, identifies some understands numbers and prepositions letters copies square, draws person w 6 parts understands opposites

dresses with little assistance, hops on one foot shoes on correct feet broad-jumps 2 feet skips bosses and criticizes, shows off ties shoes

54 (4.5)

60 (5)

prints first asks meaning of name, counts 10 words objects

FTT
Definition: wt less than 3rd percentile, falls across 2 percentile lines History: ID: HPI: anorexia, swallowing problems, GERD, vomiting, diarrhea, fevers, cough, URTI, recent travel, sick contacts PMHx: chronic disease (DM, CF, celiac, hyperthyroid, hypopituitarism, cancer, chromosomal abnormalities, infections, pancreatic insuff, kidney disease) PSHx: Pregnancy: Delivery: Nutrition: types, duration, frequency 100kcal/kg for first 10kg, 50kcal/kg for next 10kg, 20kcal/kg for each 1kg thereafter Development: Immunizations:

 FHx: delayed growth, chronic disease (DM, CF, celiac, hyperthyroid, hypopituitarism, cancer, chromosomal abnormalities, infections, pancreatic insuff, kidney disease) SHx: neglect, caregiver relationship, All: Meds: Physical: Appearance: Vitals: Growth: H+N: wasting, dysmorphic feats., cleft palate/lip, goitre, lymphadenopathy CVS: resp: GI: MSK: muscle atrophy (gluteal region), fat distribution (abdomen, face), bow-legging Neuro: gag reflex Hydration: Special Tests:

Differential: Organic: Decreased intake persistant vomiting poor milk production GERD swallowing problems anorexia Inadequate malabsorption celiac CF pancreatic insuff. Increased metabolic demand DM CHF hyperthyroid hypopituitarism cancer chronic infections inflammatory conditions (SLE, etc.) Increased losses: renal wasting chronic diarrhea metabolic diseases Non-Organic: poor feeding (inadequate type, amount, mixing) picky eater Limited growth potential: short parents dwarfism chromosomal (Turners, Down) TORCH infections

 FAS Treatment: treat cause IVF rehydration if required nutrition teaching

Fever
Definition: 2 s.d. above the mean (38.5C) History: ID: <3mos, 3mos-3yr, >3yr HPI: URTI, diarrhea, dysuria, limp/joint pain, rashes, neck stiffness, constitutional, sick contacts, travel hx, well water, animals PMHx: PSHx: Pregnancy: PROM (>18hr), infections, premature Delivery: Nutrition: Development: Immunizations: FHx: SHx: pets All: Meds: Physical: Appearance: unwell, LOC Vitals: tachycardic, tachypnea, hypotension, febrile Growth: H+N: LN, pharyngitis, AOM, teething, bulging fontanelle CVS: Resp: GI: hepatosplenomegaly MSK: joint effusion, erythematous/hot joints, rashes, petechiae Neuro: meningismus Hydration: ant fontanelle, MMM, tears Special Tests: CBCd, electrolytes, joint aspiration, LP, CXR, U/A, blood culture Differential: URTI, AOM, GAS, Lymphoma, meningitis, pneumonia/bronchiolitis/atalectasis, gastroenteritis, UTI, septic arthritis Treatment: <3mos ampicillin & gentamycin (GBS, Ecoli, Listeria) 3mos-3yrs ?ceftriaxone (Strep pneumo, H influenza, N meningitides) >3yrs based on focus of infection

Down Syndrome
Genetics: Trisomy 21 (94%), (Robertsonian) translocation (5%), mosaic Epidemiology: 1/625 live births, maternal age >35 1/200 Clinical Features: Head: brachycephaly, small low set ears, epicanthal folds, Brushfield spots, flat nasal bridge, macroglossia, micrognathia

 Chest: short neck with excess skin, C1C2 instability, hypothyroid, cardiac murmur (50%), Extremity: single palmar crease, clinodactyly, syndactyly Syndromes: Alzheimers, developmental delay, leukemia, short stature, CHD (ASD, VSD, PDA, TOF), duodenal atresia, hypotonia Diagnosis: karyotype, amniocentesis, ?blood test

FAS
Criteria Evidence of growth failure (pre or post natal) Characteristic facies: flat philtrum, thin upper vermillion border, midface hypoplasia, short palpebral fissures, narrow forehead, small eyes, ptosis, microcephaly, cleft palate/lip Behavior/intelligence: IQ 50-70, hyperactivity, learning disorder, aggressive, lack impulse control, fine motor problems, social maladaption Strong evidence for maternal drinking during pregnacy Associated Medical Problems: FTT, seizures, eyes (strabismus, poor visual acuity), VSD, ASD, horseshoe kidney, abnormal ureteric insertion, fused RU joing, C-spine fusion, scoliosis, speech pathology EtOH Withdrawal Sx:(NEED TO DOUBLE CHECK) disturbed sleep/wake, irritable, hypertonia, hyperreflexia, disordered sucking

Foreign Body Aspiration

History: acute presentation: choking event, stridor, increased WOB, cyanosis chronic presentation: recurrent wheeze, chronic cough, persistant pneumonia, persistent atelectasis risk factors: <4yo, small toys, young siblings, certain foods (peanuts, carrots, etc.) Physical: decreased air entry, tracheal deviation, stridor, cyanosis, indrawing/nasal flaring CXR: PA inspiratory/expiratory and Lat views air trapping on expiration views, flattened hemidiaphragms, pneumomediastinum, pneumonia, trachial deviation to controlateral side, radio-opaque foreign body (30%) right mainstem bronchus Treatment: rigid bronchoscopy treat pneumonia if present education

Growth Concerns
Short Stature: growth chart? parent's height? perinatal?

 PMHx? physiologic vs pathologic physiologic: constitutional delay, familial short stature pathologic: primordial: chromosomal, IUGR, skeletal dysplasias endocrine: hypothyroid, hypopituitary, growth hormone deficiency chronic disease: psychosocial: neglect History: parents' height and onset of puberty old growth charts perinatal history Physical Exam: puberty/Tanner stage dysmorphic features parent's heights neuro exam

Newborn Hip Examination

Risk Factors: 5 F's: First child, Female, Frank breech, FHx, Fluid decreased (oligohydramnios) Examination: intro, drape, wash, permission inspection: skin folds anteriorly and posteriorly palpation: Galeazzi Sign: knees unequal height when hips adducted and flexed to 90 passive ROM: should be able to externally rotate beyond 45 degrees) Barlow ("bottom"): clunk produced with posterior force applied to adducted hips flexed to 90 Ortolani ("open"): clunk produced when relocating a dislocated hip, while stablizing controlateral hip abducted and affected hip while applying an anterior force Management: Ortho consult, Pavlik harness or serial casting

Newborn Jaundice
Etiology: benign: physiological (deficiency in glucuronyl transferase), breast feeding jaundice (due to dehydration), breast milk jaundice (inhibitor of glucuronyl transferase found in milk), dehydration patholgical: o newborn: biliary atresia, idiopathic neonatal hepatitis, alpha 1-antitrypsin deficiency, infection, hemolysis o older children: autoimmunie hepatitis, viral hepatitis, Wilson's disease, biliary

obstruction DDx: Unconjugated o Pathologic: Hemolytic Intrinsic Extrinsic (Ab related, Coombs positive) Non-hemolytic: Crigler-Najjar, Gilberts, polycythemia, sepsis, hypothyroidism, cephalohematoma o Non-pathologic: Conjugated o Hepatic: infection, metabolic (galactosemia, alpha 1-antitrypsin deficiency, hypothyroid, CF), drugs, TPN o Post-Hepatic: biliary atresia, choledochal cyst History: ID: HPI: OPQRST, emesis, constipation/diarrhea, acholic stool/dark urine, melena/ hematemesis, lethargy, irritable, anorexia, fever PMHx: PSHx: Pregnancy: HCV, HBV, Rh factor, G#P# Delivery: Nutrition: breastfeeding Development: Immunizations: HBV at birth FHx: SHx: All: Meds: Physical: Appearance: jaundice Vitals: Septic (tachycardic, tachypnea, hypotension) Growth: failure to wt gain H+N: scleral icterus CVS: Resp: GI: hepatosplenomegaly MSK: jaundice, palmar creases, bruises Neuro: LOC o Early: lethargy, hypotonia, poor feeding, high-pitched cry and emesis o Late: bulging fontanelle, opishtotonic posturing, pulmonary hemorrhage, fever, hypertonicity, seizures Hydration: Special Tests: Differential: <24hr: hemolytic disease (ABO, Rh incompatibility), sepsis 1-10d: physiologic, dehydration, enclosed hemorrhage, polycythemia 1-10+d: breast milk jaundice, infections, Crigler-Najjar syndrome >7-10d: hypothyroidism, galactosemia, CF, neonatal hepatitis, biliary atresia Investigations:

 Full w/u for jaundice in first 24hr Hemolytic w/u: CBCd, blood group, peripheral smear, Coombs test, bilirubin (conjugated and unconjugated) Septic w/u: CBCd, blood and urine culture, CXR+LP (febrile, unwell) Other: TSH, G6PD Conjugated hyperbilirubinemia: AST, ALT, PT, PTT, albumin, ammonia, TSH, TORCH screen, galactosemia screen, metabolic screen, abdominal U/S, HIDA scan, sweat chloride Treatment: Goal: prevent kernicterus (unconjugated bilirubin deposits in basal ganglia) o Complications: sensorineural deafness, choreothetoid CP, gaze palsy, MR Exclude treatable causes Phototherapy must admit and watch for dehydration Exchange transfusion Dr.Stephens Rule of Thumb: Tx at 350, never let it get to 400, normal is 100Xwt in kg

Newborn Respiratory Distress

Definition: tachypnea RR>60, tachycardia HR>160 History: ID: HPI: OPQRST, febrile, lethargic, grunting, cyanosis PMHx: PSHx: Pregnancy: infection, bleeding, PROM Delivery: Meconium aspiration Nutrition: feeding tolerance, choking, grunting Development: Immunizations: FHx: SHx: All: Meds: Physical: Appearance: cyanosis, dusky, increased WOB, grunting Vitals: tachypnea, tachycardia Growth: H+N: CVS: Resp: decreased ae, crackles, grunting/intercostals indrawing/nasal flaring GI: abdominal breathing, scaphoid abdomen MSK: Neuro: altered LOC Hydration: sunken ant fontanelle, dry MM Special Tests: Differential: Pulmonary: HMD, TTN, MAS, pneumothorax, pleural effusion, congenital lung

malformations Infection: sepsis, pneumonia (GBS, Ecoli, Listeria, TORCH) Cardiac: CHD, PPHN Heme: bood loss, polycythemia Anatomic: tracheoesophageal fistula, congenital diaphragmatic hernia, upper airway obstruction (trach/laryngomalacia, choanal atresia, Pierre-Robin, mucous plug, cleft palate) Metabolic: hypoglycemia, inborn errors of metabolism Neurologic: CNS damage (trauma, hemorrhage), drug withdrawal Investigations CXR, ABG/cap gas, CBC, blood glucose, blood culture, ECHO/ECG Treatment: ABCs, based on etiology HMD surfactant deficiency, Tx: prophylactic steroids for mom, surfactant for neonate TTN delayed resorption of fetal lung fluid, Tx supportive MAS small airway obstruction, chemical pneumonitis, Tx supportive Diaphragmatic Hernia do not bag if scaphoid abdomen and BS in chest, Tx surgery PPHN R to L shunt, Tx O2, mechanical ventilation

Child with a Limp

History: ID: HPI: o limp: onset, trauma, duration, course, pain PQRST, better or worse with activity o associated symptoms: fever, weight loss, anorexia, back pain, arthralgia, voiding or stooling problems o neuro s/s o Recent trauma, viral illness or streptococcal infection, antibiotic exposure, new/poor shoes, new/increased activity, intramuscular injection PMHx: chronic medical conditions, recent viral/bacterial illness, ca, endocrine dysfunction, psychosocial problems PSHx: Pregnancy: Delivery: hip dysplasia RFs Nutrition: Development: Immunizations: FHx: CTD, IBD, hemoglobinopathy, bleeding, neuromuscular disorder SHx: affect on ADLS, new/recent sporting activities, new/poorly fitting shoes All: Meds: Abxs Physical: Appearance: well/unwell, obese Vitals: tachycardic, tachypnea, hypotension, febrile Growth: recent growth spurt H+N: uveitis CVS: Resp: URTI GI:

 o o

MSK: Swelling, erythema, atrophy, deformity, skin changes ROM, power, bulk, tone Neuro: Gait: Hydration: Special Tests:

Differential: by age: o <3: DDH, CP, transient synovitis o 3-10: Legg-Calve Perthes, growing pains o >10: Slipped Capital Femoral Epiphysis, Osgood-Schlatter, arthritis o any age: trauma, septic arthritis, osteomyelitis, cancer, infection, JIA, disuse, immobilization, Treatment: Differential Dx: Weakness: o Primary: Cerebral Palsy, Muscular Dystrophy, myositis, spinal cord lesion, GBS o Secondary: disuse, immobilization o O/E: CNS-delayed milestones, spacticity/tone, abN DTR/babinski, Gowers sign Gait-toe-walking, steppage, flexed arm, circumduction Derm-rash, midline lx (lumbosacral hair, pigmentary/vascular) MSK-muscle atrophy, pseudohypertrophy, PAINLESS Norm/abNorm ROM o Investigations: EMG, CK, genetic, MRI o Rx: preserve mobility, ROM, multi-disciplinary, underlying cause Structural: o Primary: Leg length discrepancy o Secondary: Developmental Dysplasia of the Hip, malunion/malrotation o O/E: MSK-ASIS to medial malleolus, + Galeazzi test = supine w/heels to buttocks and knees at different height from table, + trendelenburg Gait-trendelenberg o Investigations: x-ray o Rx: Orthopedic consultation, PT Pain (common): o Trauma (osseous): Salter-Harris/Greenstick Fractures, avulsion, dislocation, child abuse limp tends to be of recent onset Soft tissue: Sprain, blister, ingrown toenail, poor fitting shoes, contusion, muscle strain, child abuse Transient Inflammation: preceded by viral URTI: acute onset, otherwise well, resolve spontaneously, dx of EXCLUSION Overuse Syndromes: localized pain to knee, ankle, hip, wrist; assoc with acitivity, occurs after period of inactivity, Rx: eliminate cause/rest, conservative, analgesics Osgood-Schlatter, patellofemoral syndrome, osteochondritis Inflammatory:

 Juvenille Rheumatoid Arthritis, SLE, acute rheumatic fever, Kawasaki, Henoch-Schnlein Purpura O/E: o MSK/Derm-pain and swelling +/- localized, extremity/body positioning, decr ROM, subcutaneous nodules, rash, petechiae o HEENT-iritis, uveitis, conjunctivitis, catacracts coryza, tonsillar enlargement +/exudates o CVS-new murmur, heart failure o Gait- antalgic, unable to wt bear Investigations: CBC/d, echo, anti-ds DNA Ab, ESR, CRP Limb/Life-Threatening: o Infectious: MSK-based: Septic arthritis o Fever, significant pain, swelling and redness of joint, refusal to move or bear weight see MD < 48 h, 90% monoarticular o Dx: Joint aspiration (high WBC, + culture/G stain, glucose, protein), CBC/d, blood Cx, o Rx: Aspiration +/- debridement, IV antibiotics (Strep, staph coverage essential) Osteomyelitis o Fever, limp, disuse, less ill as septic arthritis, see MD less acutely, single site 70%, 1/3 hx of blunt trauma o Dx: early bone scan +/or MRI; late x-ray changes; ESR, CRP, blood Cx, serial WBC o Rx: IV + PO antibiotics +/- debridement Non-MSK-based: meningitis, appendicitis, epidural abscess o Non-Infectious: Structural: Slipped Capital Femoral Epiphysis: pain +/- limp, adolescents, M>F, chronic > acute Dx: AP + LAT x-ray Rx: orthopedic pinning Legg-Calve-Perthes Disease: Idiopathic Avascular Necrosis of the Hip, M>F, age 2 to 12y, limp and mild or intermittent pain, bilateral in 10% Dx: femoral head irregular, flat on X-ray Rx: PT for ROM, self-resolution in 1 to 2 y, TX to reduce pain, deformity, OA, flex/abduct braces Hematologic: Hemarthroses secondary to Hemophilia Neoplastic: Ca (Ewings, osteogenic sarcoma, leukemia) Dx: Xray, bone marrow aspirate, CT Rx: chemo, radiation, surgery O/E: febrile, hemodynamic (in)stability o MSK/Derm-painful, swollen, warm, erythematous joint, decr wt bear, ROM, petechiae o CNS-decr LOC, meningeal Sx, localized deficit o Abd-peritoneal sx, distention, decr bowel sounds

Immunization
Birth: HBV (if at risk) 2mos: DTaP-IPV, HIB, Pneumo, Meningococcal 4mos: DTaP-IPV, HIB, Pneumo, Meningococcal 6mos: DTaP-IPV, HIB, Pneumo, Meningococcal 12mos: VZV, MMR 18mos: MMR, DTaP-IPV, Pneumo, HIB 4-6yr: MMR, DtaP-IPV

gr5: HBV X3 14yr: DTaP q10yr: TD

Macrocephaly
Definition: HC >2 SD above mean History: big head: onset, progression increased ICP: nausea, diploplia, bulging fontanelles, sunsetting eyes, headache neuro: lateralizing signs, CN nerve palsies menigitis: neck pain constitutional: fever, weight loss FHx: macrocephaly Physical: growth parameters: height, weight, HC (compare to old) H+N: bulging fontanelles, cranial sutures, papilledema, sunsetting eyes neuro: orientation, CN, reflexes, sensation, motor (tone, bulk, power), gait, special tests Workup: CT, MRI LP CBC/d, blood culture

Microcephaly
always implies microencephaly classified as primary or secondary primary: chromosomal disorders, neurocutaneous disorders, neural tube defects, cerebral cleavage, migrational defects autosomal dominant (less severe, normal intellect or mild MR) autosomal recessive (moderate to severe MR) secondary: congenital infections, in utero toxin exposure, placental insufficiency, untreated maternal PKU, vascular accidents, hypoxic-ischemic insults, stroke, CNS infection, severe malnutrition, systemic disease History: HPI: IQ, neurocutaneous rashes Pregnancy: maternal infection, substance use, meds, complications Birth: birth head circumference Developmental: FHx: parents HC Physical Exam: Growth: HC H+N: fontanelles, suture lines, dysmorphic feats GI: hepatomegaly, splenomegaly

 MSK: rashes Neuro: Investigations: chromosome studies TORCH screen metabolic screen CT head, MRI

Meningitis
Risk factors: immunocompromised, neuroanatomical defects, parameningeal infection (sinusitis, mastoiditis, orbital cellulites), environmental (daycare, close contact) History: ID: 6-12mos HPI: lethargy, irritable, poor feeding, febrile, stiff neck, URTI, AOM, diarrhea, dysuria, ICP (headache, diplopia, photophobia, vomiting), travel hx, exposure to well water/pets PSHx: Pregnancy: PROM >18hrs, infections Delivery: Nutrition: Development: Immunizations: HIB, Pneumo, Meningococcus FHx: SHx: daycare, close contacts All: Meds: Physical: Appearance: septic, LOC Vitals: bradycardic, hypertension, febrile Growth: H+N: bulging fontanelle, nuchal rigidity CVS: resp: URTI GI: MSK: petechial rash Neuro: Hydration: Special Tests: o Brudzinskis sign: reflex flexion of hips and knees upon flexion of neck o Kernigs sign: reflex contraction and pain in hamstrings upon extension of leg that is flexed at the hip Differential: Viral most common 0-3mos: GBS, Ecoli, Listeria, HSV, enterovirus, CMV 3mos-3yr: S.pneumo, N.mening, TB, enterovirus, Herpes virus 6, HSV 3-21yrs: S.pneumo, N,mening, enterovirus, adenovirus, herpes Investigations: CBCd, blood cultures, blood glucose, electrolytes LP o Bacterial: WBC>1000, glucose <30

o Viral: WBC 100-500 o Herpes: WBC 10-1000, RBC 10-500 Treatment: Bacterial: vancomycin, cefotaxime Viral: supportive, acyclovir for HSV

Otitis Media
History: ear S/S: tugging at ear, draining fluid, putting things in ear, tinnitus, hearing concerns infectious S/S: fever, cough, rhinnorhea, irritable, decreased PO intake, pharyngitis exposure: sick contacts, travel, daycare, well water PMHx: previous AOM, URTIs, myringotomy tubes RFs: cleft palate, Down Syndrome, Inuit, bottle fed, decreased SES, smoker Physical: H+N: MM, pharynx, LNs, TMs (red, no light reflex, no air reflex, bulging, fluid behind, loss of inner ear structures) Etiology: bacterial: H flu, Strep pneumo, M catarhalis, GAS viral: RSV, CMV, rhinovirus Treatment: <2yrs: amox x 10d >2yrs: amox/clav x 5d if severe prophylaxis if recurrant (>3 in 6 months, or >4 in 12 months) complications: TM perf, mastoiditis, hearing loss, CN VII paralysis, cholesteatoma

Persistant Cough
History: ID: HPI:

cough: onset, duration, course, productive infectious S/S: rhinnorhea, eye symptoms, rash, diarrhea, N/V, URTI, sick contacts, travel, daycare triggers: cold air, URTIs, pollen/dust, exercise, night constitutional S/S: fever, wt loss ROS: PMHx: FTT, CF, asthma, TB, GERD, # hospitalizations PSHx: Pregnancy: Delivery: premature Nutrition:

Development: Immunizations: FHx: ashtma, eczema, allergies, CF SHx: environmental history All: Meds:

Physical: Appearance: Vitals: tachycardia, tachypnea Growth: H+N: LNs, pharynx CVS: resp: GI: MSK: Neuro: Hydration: Special Tests: Differential: asthma, foreign body, post nasal drip, infection (TB, pertussis), GERD, swallowing dysfunction, psych, CF, CHF Investigations: CXR PFTs TB skin test chloride sweat test

Pyloric Stenosis
History: ID: male, 6wks HPI: nonbilious projectile vomiting after meals PMHx: PSHx: Pregnancy: Delivery: Nutrition: intake, output (U/O, BM) Development: Immunizations: FHx: + SHx: All: Meds: Physical: Appearance: Vitals: tachycardic, hypotension Growth: weight H+N: sunken ant fontanelle, dry MM CVS: Resp:

 GI: visible peristaltic waves LUQ, Olive sign MSK: Neuro: Hydration: Special Tests: Investigations: CBCd, electrolytes, creatinine, urea, glucose, ABG/cap gas AXR 3 views Differential: Treatment: IV to correct hypokalemic hypochloremic metabolic acidosis Surgery

Rickets
Definition: deficiency in vitamin D osteopenia with disordered calcification leading increased osteoid tissue prior to epiphyseal closure Etiology: Nutritional VitD deficiency Fat malabsorption (hepatobilary dz, IBD) Defects in VitD metabolism within the kidney or liver Very low birth weight History: ID: HPI: restless, irritable, hypotonia, muscle weakness, skeletal pain PMHx: fractures, dental eruption PSHx: Pregnancy: Delivery: birth weigth Nutrition: milk Development: Immunizations: FHx: SHx: sunshine Allergy: Meds: Physical: Appearance: Vitals: Growth: length H+N: CVS: Resp: GI: hepatosplenomegaly MSK: muscle weakness, bowing of long bones Neuro: hypotonia Hydration: Special Tests: Investigations Serum Ca, PO4, PTH, vitD Radiographs increased thickness in epiphyseal growth plate, hazy metaphyseal border (trabecular pattern), diaphyses (think cortices, shafts bowed)

Differential: Treatment: Vit D supplements, phosphate supplement

SBE Prophylaxsis
Etiology: G+ cocci (90%; a-hemolytic strep, staph aureus, HACEK organisms, neisseria) Presentation: asdfkal';sflaks'df;lk'asdf Duke Criteria: Major positive BC with typical organism new onset heart murmur suggestive echo Minor vascular phenomena (splinter hemorrhages, petechiae, Janeway lesions, Roth spots) neuro phenomena (Osler's nodes) positive BC with atypical organism fever predisposing cardiac condition echo findings inconsistant with major criteria positive if: 2 major, 1 major + 3 minor, 5 minor Indications: for all dental/surgical procedures in children with CHD except: VSD/PDA repaired >6 months ago isolated ASD MP without MR Risk category: high risk = prosthetic valves, prior SBE, cyanotic HD, GU/GI operation moderate risk = all other CHD Prophylaxsis: antibiotics: amoxicillin 50mg/kg 1 hr prior to procedure penicillin allergy: clindamycin 20mg/kg 1 hr prior to procedure high risk: amp+gent x 2 doses dental hygiene minimal use of central lines

Seizures
History: seizure: OPQRST, eye deviation, facial tics, drooling, tonic/clonic/myoclonic, N/V, urine/fecal incontinence, tongue biting infection: URTI, OM, pharyngitis, meningitis, rash, N/V, diarrhea, cough toxins: missed dosages, poisons trauma PMHx: previous diagnosis, investigations

Physical: H+N: neuro: Differential: infection, toxin, trauma, structural brain, idiopathic Treatment: ABCs >5min give Ativan, if continues load with phenobarb longterm anti-epileptics: partial: carbemazepam, phenytoin general: valproic acid, phenobarb absence: ethosuxomide, valproic acid myoclonic: valproic acid, clonazepam infantile spasms: steroids (prednisone, ACTH), Vigabatrin

Rashes
History: ID: HPI:

Rash S/S: onset, pain, itch, location, quality, radiation/spread, aggrevating/alleviating, timing (esp with fever) Infectious S/S: fever, N/V, diarrhea, otalgia, phayngitis, rhinorrhea, cough, stiff neck, lethargy, appetite, sleep Exposure: sick contacts, travel, well water, day care PMHx: PSHx: Pregnancy: Delivery: Nutrition: new foods Development: Immunizations: FHx: SHx: triggers (pets, enviromental, soaps) All: Meds: Physical: H+N: mucous membranes, LNs, palms, soles Derm: location appearance: papules, macules, patch, nodules, scales texture

Varicella
(see handouts)