Bug life
Most common cause of sore throat in kids
1. Virus - Adeno, Rhino/Entero, EBV, Corona, Flu
2. Group A β-hemolytic Streptococcus (Strep pyogenes)
A toddler presents with bright red pinpoint dots on the bilateral lower legs. The lesions do not blanch, are raised, are painless, and are not itchy. The child has no other symptoms. What is the diagnosis?
IgA vasculitis/HSP. What if this kid had belly pain? Hematuria?
A newborn presents for their one week post delivery check and parents are concerned about the odor of the umbilical stump. They notice discharge from the area as well. On your exam the entire area is normal appearing and baby is well. What’s the diagnosis?
Norma umbilical drainage/umbilical granuloma
A boy comes in with abdominal pain. The history is otherwise unremarkable. You do an HEENT exam, a heart and lung exam. You examine the belly and he has bilateral abd pain. What’s the next best step?
A GU exam.
4 yr old child presents to your clinic with leg pain, fever, fatigue, petechiae and anemia. You suspect cancer. You do labs and find WBC 40K with bands and abnormal smear. What’s the most common cause?
Acute lymphoblastic leukemia. Great prognosis. >90% survival if favorable genetics, B cell, and WBC <50K.
less favorable if T cell, Phil Chromosome, mets, WBC > 50, age <1 or >10
A child represents to your clinic after being diagnosed with AOM, he’s not improving on Amox, what treatment would you recommend
If first-line therapy fails (worsening or no improvement within ~48–72 hours)
A 3mo old comes in with respiratory distress. Parents state she had URI sx for 3 days then today had increase work of breathing. On exam, the child has tachypnea, tachycardia, rhinorrhea, diffuse rhonchi and subcostal retractions. What’s the diagnosis?
Bronchiolitis. What’s the most common cause?
A 3 day old full term baby presents with vomiting. Parents state he vomits with every feed. You try to feed the baby in the office and he vomits the entire feed. What’s the worse case scenario?
Malrotation with Volvulus.
A baby comes in fussy. The fussiness started after the bath. No fever or sick symptoms. On exam, his heart, lungs, HEENT, Abd, and GU exam is normal. What should you do next?
Check for hair tourniquet or corneal abrasion.
A 4 yr old presents for constipation. Parents state he hasn’t pooped in 2 weeks. They have tried OTC remedies including suppository, enema, miralax, and prunes with no relief. On exam, he looks pregnant. His abd is distended, firm, and concerning. You do XRAY and they say he has a mass. What’s the working diagnosis and next best step?
Wilm’s tumor - Most common renal malignancy, 2-5yr olds, Painless abdominal mass, hematuria, hypertension (↑ renin)
Palpate lightly → risk of tumor rupture
A 7 day old presents to the clinic for evaluation. He is found to have a fever: what three bacterial organisms are most likely to cause infection?
A child presents with sore throat for 3 days. Today they awoke with a muffled voice and worse pain. They present to the clinic and exam shows tonsillitis exudate, advanced displacement of the palate, and uvulae deviation to the right. What’s the diagnosis?
Peritonsillar abscess - what’s the cause?
A 1-month-old baby presents to the clinic with fever. Mom states the baby was born at 37weeks PROM and spent two weeks in the NICU. Since being home, she is well, until this evening when she was fussy and found to have a fever. Exam shows no source. What is the most likely diagnosis?
Sepsis/bacteremia until proven otherwise. CBC diff, Blood cultures, CRP, Procalcitonin, Respiratory swab, Urine analysis, gram stain and culture, LP if no source.
An athlete presents for ankle pain. He states he was playing in a sporting game last night and hurt his right ankle. The ankle is bruised, swollen, and exquisitely tender. Besides an ankle x-ray what else should you obtain and why?
A tibia/fibula xray to r/o
Maisonneuve fracture = a high-risk ankle injury that’s easy to miss. A proximal fibular fracture caused by external rotation of the ankle, with syndesmotic disruption. classic triad:
A 5 yr old child presents to clinic with left eye swelling. Parents state he was fine until they went to see grandma who commented that his left eye looks “pushed out”. They deny trauma or infectious symptoms. On exam, he has unilateral proposes, periorbital swelling, ptosis, and eyelid erythema
Orbital rhabdomyosarcoma: common primary orbital malignancy in children. It is a malignant tumor of skeletal muscle origin. MRI orbit to diagnose. Tx: chemo and radiation. Prognosis >90% survival W/treatment
A child comes to the clinic with knee swelling and pain. You are concerned for an infection. What is the appropriate workup for this patient to evaluate for knee infection?
1. Labs: CBC diff, Blood cx, ESR, CRP, Lyme, GC
2. X-rays if trauma or US if effusion
A 2 year old presents to the clinic with fever for 6 days and irritability. He had pink eye a few days ago and sore throat so mom took him to the urgent care and they diagnosed him with a virus. On exam, he has pharyngitis, conjunctivitis and rash. Mom thinks his hands are swollen as well. What’s the diagnosis?
Kawasaki disease. CRASH and burn.
Conjunctivitis, Rash, Adenopathy, Strawberry tongue, and Hand and Food swelling/peeling.
A patient with sickle cell presents with acute onset chest pain. The child was at school them developed chest pain. They called the specialist who said go to the ED. What’s the diagnosis and what’s the workup?
A 18 yr old female presents for trouble breathing. She states she is generally healthy but since starting college, she’s developed difficulty breathing. Her roommate said it could be asthma. She went to the student health and they gave her a puffer. It only helps a little. Her exam is normal. What additional questions could you ask to figure out the diagnosis?
Vocal cord dysfunction - ask inspiratory vs expiratory.
IA 19 yr old male presents to the clinic alone with abdominal swelling. He has been working out more in the gym to bulk up but lately his belly feels really big and bloated. No fevers. Some nausea and decreased appetite bc he gets full easily. He’s noticed some weight loss but states he’s eating cleaner for soccer. No other systemic symptoms. On exam, you feel a mass in the middle abdomen. You do a CT and he has a tumor. What’s the most common cause? What tests do you do?
Germ cell/testicular cancer. CBC diff, CMP, Alpha fetal protein, HCG as a tumor marker, LDH, Uric acid, Urine studies.
A teen comes in with a blistering rash. Parent says the child has had fever, fatigue and is very irritable. On exam, the skin is sunburn red and tender, there are flaccid bullae that rupture easily while other areas are desquamated areas. The mucous membranes and GU area are spared. What’s the diagnosis and treatment?
Staph Scalded Skin Syndrome. Treat with IV anti-staphylococcal antibiotics
A 14 year old female patient presents to clinic due to abdominal pain for two weeks. She’s generally well, no menses yet, denies social risk factors, and no fever, trauma or N/V/D. Parents are frustrated because this is their third visit to healthcare. Visit one to clinic showed constipation. Visit two ED showed no appendicitis. Visit three at urgent care showed no UTI. Exam is notable for bilateral and suprapubic pain. You repeat urine and it’s negative. You do a AXR and she has minimal stool. Labs are normal. What’s the diagnosis?
Hematocolpos.
A 13yr old with a history of HIV presents due to fever. He has a port for meds. He has a G tube as well for feeds and failure to thrive. He is lethargic and minimally responsive. What’s the workup and potential differential dx?
CD4 >500
Mostly normal population stuff:
CD4 200–500
↑ risk of:
CD4 <200
Classic opportunistic infections:
CD4 <100
CD4 <50
Think disseminated infections:
A 2 yr old girl presents to the clinic with difficulty walking. Parents deny trauma, fever or infectious symptoms. On exam, the vitals are normal but the child refuses to walk. She can stand but is very wobbly. She prefers to lay down rather than sit up. Neuro exam shows ataxia. Her eyes have abnormal movements. What’s the diagnosis and workup?
Ataxia in kids can be central due to brain swelling, cerebellar tumor, ADEM, acute cerebellar ataxia, neuroblastoma, or toxic exposures. Workup should include labs, drug screen, CT/MRI
A 16 yr old presents to the clinic with leg pain after a gym injury at school. Exam shows pain on the right femur. You do X-rays. The radiologist calls and says the distal femur had periosteal elevation and a sunburst pattern and is suspicious. What’s the dx and what do you do?
Most common benign bone tumor in children:osteochondroma
Most common malignant primary bone tumor in children/adolescents: Osteosarcoma, MRI, chemo and surgery