angel solomon, ms pa-c

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


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


Infant & Childhood Development Language cont…

3 year – 75% comprehensible

4 year – 100% comprehensible

Age 7 or 8 – speech, language, articulations close to adult


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


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


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


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


Abnormal Growth Failure to Thrive

Short Stature


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


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


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


SHORT STATURE 1. Familial Short Stature

2. Constitutional Growth Delay

3. Chronic Conditions


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


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


HEENT URI

Acute Otitis Media

Chronic Otitis Media

Otitis Externa

Croup

Amblyopia

ENT Foreign Bodies


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!!!


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


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


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)


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


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


Courtesy of Wikepedia Rutgers PANCE/PANRE Review Course

http://en.wikipedia.org/wiki/File:Esotropia-uncorrected.jpg

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


Which of the following is the most common presenting symptom of epiglottitis in a child?


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:


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?


Alb

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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?


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


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


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


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


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


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


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


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


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


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!


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.


Cardiology Acquired Heart Disease

Rheumatic Fever

Functional murmurs

Still’s Murmur

Venous Hum

Congenital Heart Disease

Acyanotic Lesions

Cyanotic Lesions


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


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


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


Atrial Septal Defect Communication between right and left atria

children asymptomatic

S2 widely split and fixed

Tx: surgical repair


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


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


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


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


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


Courtesy of Wikipedia Rutgers PANCE/PANRE Review Course

http://upload.wikimedia.org/wikipedia/en/7/78/SalterHarris.png

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?


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?


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?


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


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


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


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


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?


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


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


Reproduced with permission of author, Dr Frank Gaillard

S

A

L T R


http://upload.wikimedia.org/wikipedia/en/7/78/SalterHarris.png

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


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


http://en.wikipedia.org/wiki/File:MaleWithOsgoodSchlatter.jpg

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


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


Courtesy of Centers for Disease Control and Prevention


“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


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


http://en.wikipedia.org/wiki/File:Rash_of_rubella_on_skin_of_child%27s_back.JPG

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


Roseola: “Roseola infantum”

HHV-6

Ages 3 months - 4 years


Maculopapular rash

High fever (102-105) for 3-5 days

Fever starts resolving, THEN rash appears

Tx is supportive


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

Parvovirus

School aged children


Red facial rash and lacy, pink macular rash on torso & extremities

Pregnant woman at risk: hydrops fetalis

Tx is supportive


Courtesy of Wikepedia


http://en.wikipedia.org/wiki/File:Fifth_disease.jpg

Courtesy of wikepedia Rutgers PANCE/PANRE Review Course

http://en.wikipedia.org/wiki/File:Fifth_desease.jpg

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


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

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


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


Recommended Childhood Immunization

Schedule, United States

Rotavirus

Hepatitis A

Varicella

Pertussis

Meningococcal

Human papilloma virus


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

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


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


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


angel solomon, ms pa-c

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