In the Clinic
A 10 year old's permanent tooth is knocked out while playing in the backyard. The mother calls to ask what to do. She is not able to reimplant the tooth because the child is uncooperative. You get in touch with a dentist on call who will meet them soon at his office. You tell her to bring the tooth in what common household liquid?
Cold Milk.
If the tooth cannot be reimplanted, it should ideally be kept in Hank's Balanced Salt Solution or Save-a-Tooth solution. If these are not available, then cold milk followed by alive, physiologic saline solution or any available isotonic solution is best.
Children with Spina Bifida or Congenital urogenital problems have an increased risk of being allergic to which common hospital substance?
Latex
This is common because of repeated exposure to latex from many medical procedures and surgeries. Latex allergy is due to sensitization to protein - mainly hevein. Cross-reactivity can occur with papaya, kiwi, banana, potato, avocado, tomato and chestnuts.
A woman with SLE presents with a history of multiple miscarriages. What is the likely antibody abnormality responsible for this?
Antiphospholipid antibodies
Women with SLE and history of recurrent miscarriages are likely to have antiphospholipid antibodies. These include lupus anticoagulant, anticardiolipin, and beta-2-glycoprotein-1 antibodies. Additionally, these antibodies can cause thrombocytopenia, livedo reticularis, and/or blood clots in 25% of patients
What is the most common genital problem in newborn males?
Cryptorchidism
Occurs in 33% of premature boys and 3-4% of term males. By 1 year of age the testes have descended in all but 0.3%.
When and where are the graduation ceremony and the afterparty?
Ceremony - 5:30 PM (Doors at 5 PM) at Miller Auditorium
Afterparty - 8:30 PM at 600 Kitchen and Bar
A previously unimmunized child presents at 4 months of age. Which routinely recommended vaccine is now too late to give?
Rotavirus
If not given the first dose by 14 week and 6 days of age, CDC recommends not giving at all. Also do not administer the last dose if patient is over 8 months old.
A newborn presents with the following findings:
Abscence of optic chiasm
Optic nerve hypoplasia
Agenesis of corpus callosum
Hypothalamic insufficiency
What is the likely syndrome?
Commnly involves the HPA and can affect the anterior, posterior or both axes. Associated with and abnormality in transcription factor HESX1
A newborn presents with congenital complete heart block and macular rash on scalp and face.
What 2 antibodies does the mother likely have that have affected this newborn?
Anti-SSA (Anti-Ro) and Anti-SSB (Anti-La) Antibodies
This newborn has neonatal lupus as a result of transplacentally acquired maternal antibodies. In mothers with these antibodies, the risk of passing them is <5-10% but is significant enough that the mother and fetus should be followed through pregnancy. Postpartum, follow baby up to 12 months.
You find a hydrocele on a 2 month old. When should the child undergo repair if it persists?
1 year of age
Hydroceles that last past 1 year of age should be surgically repaired. Noncommunicating hydroceles usually resolve before this time.
What was the number one movie at the box office last weekend?
Solo: A Star Wars Story
A child is to have a PPD and MMR today. Can you give both today at the same office visit and what is the reaction you are concerned about?
Yes. If you give MMR today and not PPD, then you must wait 4-6 weeks before placing PPD because measles vaccine can suppress tuberculin reactivity. The suppression is not immediate so it is fine to give both today.
A 14 year old girl presents with the following findings:
Abdominal pain, Lower extremity swelling without urticaria, Her father has a similar condition
What is the most likely diagnosis?
Hereditary Angioedema
Autosomal dominant complement disorder caused by a defect in C1 inhibitor enzyme function with secondarily decreased C4 levels. Screen first by checking C4 levels. If low, look for a decreased C1-INH functional assay. If this is low, it is HAE type I. If normal, it is due to non-functioning C1-INH enzyme and it is HAE II.
A 15 year old presents with arthritis. You are concerned about JIA vs. SLE. Xrays of the affected joints are taken. What do you expect to see in JIA compared to SLE in terms of X-Ray findings?
JIA can cause erosive joint damage; SLE does not
Realize that JIA can cause juxta-articular osteopenia and erosive joint damage but late in the course. In contrast, SLE does not usually cause erosive damage. Be aware though that SLE commonly causes avascular necrosis - especially in hips, knees and shoulders. SLE can cause nonerosive joint abnormality called "Jaccoud arthropathy", a reversible subluxation of metacarpal-phalangeal joints of the hands.
You start an aminoglycoside in a child. 8 days later his creatinine rises and his FENa is not low. What is the mechanism by which the aminoglycoside likely caused acute kidney injury?
Acute Tubular Necrosis
ATN is the most common cause of intrarenal AKI (~75%) in adults an is very common in children. Aminoglycosides are one of several types of drugs that can induce ATN. They cause proximal tubule damage resulting in nonoliguric ATN. ATN is usually delayed 7-10 days after starting therapy and early therapeutic levels are not a guarantee of safety.
What did Prince William and Princess Kate name their new baby?
Prince Louis Arthur Charles
The mother of an 18 month old boy is concerned that his "eyes sometimes look crossed". Name two tests that may be used in this age group to evaluate for strabismus.
Corneal light reflex and Unilateral cover test.
In toddlers and preschool aged children, use the corneal light reflex test to confirm the the position of the corneal reflection is the same in both eyes. Perform the test by holding a with about 3 feet from both eyes. Displacement of the corneal light reflection in 1 eye suggests strabismus. Perform the unilateral cover test by covering and uncovering each eye while the child is looking straight ahead. Results are consistent with strabismus if there is movement in the uncovered eye when the opposite eye is covered vs uncovered.
10 year old presents with:
Asymmetric face with broad nose, prominent forehead and triangular jaw
Eczema
Scoliosis
Hyperextensible joints
Recurrent cold abscesses with S. aureus and S. pneumo
Eosinophilia
What is the most likely diagnosis?
Hyper IgE Syndrome (Job Syndrome)
Deficiency of signal transducer an activator of transcription 3 (STAT3) that results in multi-system involvement. Will also have postinfectious pulmonary cysts (pneumatoceles) and 2 rows of teeth due to delayed dental exfoliation. Initially will have elevated IgE levels but may fall to normal later in life. High IgE is not needed to make the diagnosis.
A 14 year old girl presents with chronic right upper arm pain that is aggravated by stroking her skin (allodynia), complaints that the arm appears swollen and warm, occasional mottling of the skin in this area. What is the likely diagnosis?
Complex Regional Pain Syndrome
Difficult to diagnose because no lab or radiology studies to help. Distinguish from fibromyalgia because pain is localized to 1 area of the body. Allodynia is classic. Nuclear scintigraphy may be useful in adults but not yet in children. May be preceded by soft tissue injury.
What are the most common sites of thromboses in a child with nephrotic syndrome?
Renal Vein and Sagittal Sinus
In Children with nephrotic syndrome, these are the most common locations for clots, followed by the pulmonary and femoral arteries. Almost all nephrotic children have a hypercoagulable state and about 20% will have a thrombotic event that is clinically silent.
What happened to Becca which led to her being the new Bachelorette?
After winning the Bachelor, she was dumped on national television (for like, an hour) so her fiancee could date the runner up.
A preterm girl born at 26 weeks gestation is now 2 months chronologic age and remains in NICU. She is clinically stable and has steady growth. She will likely stay in NICU for several more weeks to gain additional weight. List the vaccinations she may receive prior to discharge from the NICU.
Hepatitis B, DTaP, PCV13, Hib, IPV
All immunizations recommended at 2 months of age may be given simultaneously to preterm infants except the live oral rotavirus. Defer this until discharge from NICU to prevent nosocomial spread of the vaccine virus. Use combination vaccines to reduce the number of injections of the inactivated vaccines. If decreased muscle mass/limited injections sites make it difficult to administer 3-4 injections simultaneously, give the vaccines at 2 week intervals to avoid superimposing local reactions.
A Caucasian child has early-onset SLE. Which immune deficiency should you look for?
C2 deficiency
The most common complement deficiency in North American Caucasians and results in increased risk of rheumatoid diseases - especially SLE. Consider it in patients with early-onset SLE.
A 17-year-old female presents with recurrent buccal aphthous ulcers, painful recurrent genital aphthous ulcers, anterior uveitis and papilledema, erythema nodosum, positive pathergy test. What is the most likely diagnosis?
Bechet Disease
Classic triad of painful recurrent oral and genital lesions and inflammatory eye disease. Key finding is buccal aphthous ulcers (found in nearly 100% of patients). Erythema nodosum and necrotic folliculitis are common. Pathergy test might be positive.
A young boy presents with the following:
Absence of abdominal wall musculature, Cryptorchidism, Dilation of prostatic urethra, bladder, and ureters.
What is the syndrome with these findings?
Prune Belly Syndrome (Eagle-Barrett Syndrome, Urethral Obstruction Malformation Complex)
Occurs in 1/40,000 boys, rarer in girls who make up 5% of cases. The syndrome gets its name from the shriveled, prune-like skin on the infant's abdominal wall. It can have varied presentations, but the most common is a group with significant anatomical genitourinary anomalies but normal renal function. It can be confused with posterior urethral valves in utero.
What is the number one song on the Billboard Top 100 Pop chart?
The Middle - Zedd, Maren Morris, Grey