Peds OSCE PackNick GrahamNic ToddZak 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, nasalflaring, 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 marrowinfiltration, ?sepsis

• Macrocytic• B12/folate deficiency, liver disease, EtOH, hypothyroidism, aplastic,

Fanconi’s anemiaTreatment:

• 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 Moderate Asthma Severe Asthma Near-Death

ClinicalFeatures

• nighttimecough

• SOB wexercise

• + B-agonistuse

• abbreviatedspeach

• SOB at rest• ++ B-agonist

use (>q4h)

• altered LOC• difficulty speaking• laboured resps• persistant

tachycardia• no relief w

B-agonists

• exhausted,confused

• diaphoretic,cyanotic

• apnea• decreased resp

effort• failing heart rate

O2 Sats >95% >92 - 95% <92% <90%

PFTs(PEFR,FEV1)(as % ofpredicted/personalbest)

>75% 50 - 75% <50% inappropriate

Treatment

• B-agonists ±O2

• ±systemiccorticosteroids

• B-agonists + O2• systemic

corticosteroids• ±anticholinergics

• ±intubate• B-agonists + O2• systemic

corticosteroids• ±anticholinergics• ±methylxanthines

• ±intubate• B-agonists + O2• systemic

corticosteroids• ±anticholinergics• ±methylxanthines• ±magnesium

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, aerosolizedchemicals, 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 foldsPhysical

• palpate for gonads/testes• normal 3.5cm, normal clitoris 1.5cm, microphallus <2cmInvestigations:• karyotype• Adrenal steroids (17OH progesterone), electrolytes, U/S, MRIDifferential• male pseudohermaphrodite (XY, XO, XO/XY with palpable gonads)• female pseudohermaphrodite (XX without palpable gonads) – CAH (Tx - replacement ofglucocorticoids and mineralocorticoids)• mixed gonadal dysgenesis• true hermaphrodite – both male and female gonadal tissue present but may/not befunctional (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, imperforateanus)

• 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 edgeo Costophrenic angleso Cardiac sizeo Describe markings – coarse/reticular/ground glass, diffuse/patchy, symmetrical/

noto Fissures

• Findingso Bronchiolitis – hyperinflation (flattened diaphragms, pneumothorax,pneumomediastinum, increased AP diameter), increased bronchovascular markings,atalectasis, interstitial infiltrateso Asthma – hyperinflation, increased lung markings, atalectasis, peribronchialcuffing, pneumothorax, lobar collapseo Pneumonia – lobar (consolidation in single lobe with air bronchograms),bronchopneumonia (diffuse streaky infiltrates)o Foreign body – inspiration/expiration views (hyperinflation on expiration), Rightmainstem bronchuso Transient tachypnea of the newborn (TTN) – fluid in fissures, cardiomyopathy,increased vascular markingso Meconium aspiration – coarse, patchy, asymmetric, air trappingo 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 andneck, 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, cyanosiso Resp: stridor, decreased ae, increased WOB (tracheal tug)

• dDx: Epiglottitis – EMERGENCY, larygomalacia/tracheomalacia• Treatment: 95% no admission (3-7d), Repiratory isolation, IV hydration, humidified/coolair, 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) FM Language GM Social

1 grasp reflex facial responseto sounds

lifts head inprone position stares at face

2 follows w eyespast midline coos

lifts head inprone position to45o

smiles inresponse toothers

4 hands open,objects to mouth laughs/squeals

sits: headsteady, turnstoward voice

smiles spont,rolls to supine

6 palmar grasp babblessitsindependently,stands w help

reaches for toys,recognizesstrangers

9 pincer grasp"mama, dada",comprehends"no"

pulls to stand feeds self, wavesbye-bye

12 (1) helps turn pagesof book

2-4 words,followscommand wgesture

standsindependently,walks, one handheld

points to indicatewants

15 scribbles4-6 words,followscommand

walksindependently

drinks from cup,imitatesactivities

18 (1.5) turns pages ofbook

10-20 words,points to 4 bodyparts

walks up steps feeds self wspoon

24 (2)solvessingle-piecepuzzles

combines 2-3words, uses "I"and "you"

jumps, kicks ball removes coat,verbalizes wants

30 (2.5)imitateshorizontal andvertical lines

names all bodyparts rides tricycle

pulls up pants,washes, drieshands

36 (3)copies circle,draws person w3 parts

gives full name/age/sex, names2 colors

throws balloverhand, walksup stairs

toilet trained,puts on shirt,knows front fromback

42 (3.5) copies crossunderstands"cold", "tired","hungry"

stands on onefoot for 2-3 sec associate play

48 (4)

counts 4 objects,identifies somenumbers andletters

understandsprepositions hops on one foot

dresses withlittle assistance,shoes on correctfeet

54 (4.5)copies square,draws person w6 parts

understandsopposites

broad-jumps 2feet

bosses andcriticizes, showsoff

60 (5)prints firstname, counts 10objects

asks meaning ofwords skips ties shoes

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 1kgthereafter

• 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 (38.5°C)History:• ID: <3mos, 3mos-3yr, >3yr• HPI: URTI, diarrhea, dysuria, limp/joint pain, rashes, neck stiffness, constitutional, sickcontacts, 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 cultureDifferential: URTI, AOM, GAS, Lymphoma, meningitis, pneumonia/bronchiolitis/atalectasis,gastroenteritis, UTI, septic arthritisTreatment:• <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%), mosaicEpidemiology: 1/625 live births, maternal age >35 1/200Clinical Features:• Head: brachycephaly, small low set ears, epicanthal folds, Brushfield spots, flat nasalbridge, 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, hypotoniaDiagnosis: 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, lackimpulse control, fine motor problems, social maladaption• Strong evidence for maternal drinking during pregnacyAssociated Medical Problems:• FTT, seizures, eyes (strabismus, poor visual acuity), VSD, ASD, horseshoe kidney,abnormal ureteric insertion, fused RU joing, C-spine fusion, scoliosis, speech pathologyEtOH 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 ananterior 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 inmilk), dehydration• patholgical:o newborn: biliary atresia, idiopathic neonatal hepatitis, alpha 1-antitrypsin deficiency,infection, hemolysiso older children: autoimmunie hepatitis, viral hepatitis, Wilson's disease, biliary

obstructionDDx:• Unconjugatedo Pathologic:• Hemolytic• Intrinsic• Extrinsic (Ab related, Coombs positive)• Non-hemolytic: Crigler-Najjar, Gilberts, polycythemia, sepsis, hypothyroidism,cephalohematomao Non-pathologic:• Conjugatedo Hepatic: infection, metabolic (galactosemia, alpha 1-antitrypsin deficiency, hypothyroid,CF), drugs, TPNo 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: LOCo Early: lethargy, hypotonia, poor feeding, high-pitched cry and emesiso 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, TORCHscreen, 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 airwayobstruction (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 activityo associated symptoms: fever, weight loss, anorexia, back pain, arthralgia, voiding orstooling problemso neuro s/so Recent trauma, viral illness or streptococcal infection, antibiotic exposure, new/poorshoes, new/increased activity, intramuscular injection• PMHx: chronic medical conditions, recent viral/bacterial illness, ca, endocrinedysfunction, 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:

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

Differential:• by age:o <3: DDH, CP, transient synovitiso 3-10: Legg-Calve Perthes, growing painso >10: Slipped Capital Femoral Epiphysis, Osgood-Schlatter, arthritiso 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, GBSo Secondary:• disuse, immobilizationo O/E:• CNS-delayed milestones, spacticity/tone, abN DTR/babinski, Gower’s sign• Gait-toe-walking, steppage, flexed arm, circumduction• Derm-rash, midline lx (lumbosacral hair, pigmentary/vascular)• MSK-muscle atrophy, pseudohypertrophy, PAINLESS Norm/abNorm ROMo Investigations: EMG, CK, genetic, MRIo Rx: preserve mobility, ROM, multi-disciplinary, underlying cause• Structural:o Primary: Leg length discrepancyo Secondary: Developmental Dysplasia of the Hip, malunion/malrotationo O/E:• MSK-ASIS to medial malleolus, + Galeazzi test = supine w/heels to buttocks and kneesat different height from table, + trendelenburg• Gait-trendelenbergo Investigations: x-rayo 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, resolvespontaneously, dx of EXCLUSION• Overuse Syndromes:• localized pain to knee, ankle, hip, wrist; assoc with acitivity, occurs after period ofinactivity, Rx: eliminate cause/rest, conservative, analgesics• Osgood-Schlatter, patellofemoral syndrome, osteochondritis• Inflammatory:

• Juvenille Rheumatoid Arthritis, SLE, acute rheumatic fever, Kawasaki, Henoch-SchönleinPurpura• O/E:o MSK/Derm-pain and swelling +/- localized, extremity/body positioning, decr ROM,subcutaneous nodules, rash, petechiaeo HEENT-iritis, uveitis, conjunctivitis, catacracts coryza, tonsillar enlargement +/-exudateso CVS-new murmur, heart failureo Gait- antalgic, unable to wt bear• Investigations: CBC/d, echo, anti-ds DNA Ab, ESR, CRP• Limb/Life-Threatening:o Infectious:• MSK-based: Septic arthritiso Fever, significant pain, swelling and redness of joint, refusal to move or bear weight –see MD < 48 h, 90% monoarticularo Dx: Joint aspiration (high WBC, + culture/G stain, glucose, protein), CBC/d, blood Cx,o Rx: Aspiration +/- debridement, IV antibiotics (Strep, staph coverage essential)• Osteomyelitiso Fever, limp, disuse, less “ill” as septic arthritis, see MD less “acutely”, single site 70%,1/3 hx of blunt traumao Dx: early – bone scan +/or MRI; late – x-ray changes; ESR, CRP, blood Cx, serial WBCo Rx: IV + PO antibiotics +/- debridement• Non-MSK-based: meningitis, appendicitis, epidural abscesso 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 to12y, 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/abductbraces• Hematologic: Hemarthroses secondary to Hemophilia• Neoplastic:• Ca (Ewing’s, osteogenic sarcoma, leukemia)• Dx: Xray, bone marrow aspirate, CT• Rx: chemo, radiation, surgery• O/E: febrile, hemodynamic (in)stabilityo MSK/Derm-painful, swollen, warm, erythematous joint, decr wt bear, ROM, petechiaeo CNS-decr LOC, meningeal Sx, localized deficito Abd-peritoneal sx, distention, decr bowel sounds

Immunization

Birth: HBV (if at risk)2mos: DTaP-IPV, HIB, Pneumo, Meningococcal4mos: DTaP-IPV, HIB, Pneumo, Meningococcal6mos: DTaP-IPV, HIB, Pneumo, Meningococcal12mos: VZV, MMR18mos: MMR, DTaP-IPV, Pneumo, HIB4-6yr: MMR, DtaP-IPV

gr5: HBV X314yr: DTaPq10yr: 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 Brudzinski’s sign: reflex flexion of hips and knees upon flexion of necko Kernig’s sign: reflex contraction and pain in hamstrings upon extension of leg that isflexed at the hipDifferential:• 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, herpesInvestigations:• CBCd, blood cultures, blood glucose, electrolytes• LPo Bacterial: WBC>1000, glucose <30

o Viral: WBC 100-500o Herpes: WBC 10-1000, RBC 10-500Treatment:• 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 viewsDifferential:Treatment:• IV to correct hypokalemic hypochloremic metabolic acidosis• Surgery

Rickets

Definition: deficiency in vitamin D• osteopenia with disordered calcification leading increased osteoid tissue prior toepiphyseal closureEtiology:• Nutritional VitD deficiency• Fat malabsorption (hepatobilary dz, IBD)• Defects in VitD metabolism within the kidney or liver• Very low birth weightHistory:• 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)