Bread & Butter
2 y/o M BIB mom to clinic with worsening right ear pain. Mom says right ear is more prominent, like it's "sticking out from his head". VS show fever. Exam remarkable for erythematous bulging TM, and erythema, edema, tenderness posterior to external ear. What is the diagnosis and treatment?
Acute Mastoiditis (most common complication of AOM)
IV Antibiotics and drainage (tympanostomy, mastoidectomy)
What physical exam finding on forward bend test should prompt further evaluation with x-ray of spine?
Spinal curvature (thoracic or lumbar prominence) >/= 7 degrees (5 degrees in overweight child) suggests clinically significant scoliosis and requires PA and lateral XR spine to confirm diagnosis.
8 y/o with Hemophilia A sustains minor head trauma in MVC. Pt lost consciousness for 15 seconds, c/o mild headache, and has 2-cm frontal hematoma. The best next step in management (bonus: treatment for + finding?)
CT head noncontrast
Factor XIII or IX
6 y/o M in clinic for routine health maintenance exam. On exam, you see multiple scattered hyperpigmented macules on trunk, right thigh, left arm, and BL inguinal creases. Exam is otherwise WNL. What other diagnostic screening test should you order?
A. biopsy skin lesions
B. audiologic examination
C. reassurance and observation
D. ophthalmolgic examination
E. serum growth hormone level
Ophthalmolgic evaluation for optic pathway gliomas
BL gliomas pathognomonic for NF1
May be initially asymptomatic, but progress to vision loss
You are speaking with patient's mom regarding febrile seizure, now resolved. Mom asks you what this means regarding his chance of having another seizure in the future. You tell her:
Increased risk ~30% of at least one recurrence
Increased risk of developing epilepsy
Child brought in for skin lesions. Mom describes flesh-colored papule initially, but pt has since developed multiple similar lesions. On exam, you see umbilicated skin-colored papules. What is the diagnosis and how did the pt get it?
Molluscum contagiosum.
Skin-to-skin contact
Describe Osgood Schlatter disease.
Apophysitis of tibial tubercle 2/2 repeated microtraumas
16 y/o M BIBEMS for severe abdominal pain. Pt was playing soccer when he felt acute onset of LUQ pain, constant, sharp, worse with inhalation. Reports several days of fever, sore throat, fatigue 2 weeks ago. Temp 99, BP 86/52, HR 122, RR 24, sat 96% on RA. On exam, he appears uncomfortable and has LUQ rebound tenderness. Of the following which is the best next step? CT A/P, diagnostic peritoneal lavage, ex lap, monospot testing, volume resuscitation
volume resuscitation
spontaneous splenic rupture post viral causing signs of hypovolemic shock and LUQ pain
Name 2 features of Turner syndrome seen in a newborn on examination.
Or
Name 2 screening tests that must be performed after diagnosis.
short, webbed neck
Lymphedema of hands & feet
Broad chest with widely spaced nipples
Low hairline (on posterior neck)
Narrow/high-arched palate
Echo
4-extremity blood pressure
Renal u/s
First line treatment for Kawasaki disease (2 things).
IVIG and Aspirin
15 m/o M in clinic for fatigue. Mom says he used to take 1x 2-hr nap in the afternoons, but recently takes additional 2-hr nap in the mornings x 2 weeks. Pt is picky eater and has 32 oz total of cow's milk per day. On exam, he is tired-appearing, pale, nail beds pale. Labs show Hgb 8.1, lead levels undetectable. You diagnose iron deficiency anemia, and prescribe ferrous sulfate to take between meals with OJ.
What will the iron studies show besides decrease Hgb? (MCV, RDW)
Which of the following will be the first level to increase? ferritin, hemoglobin, hematocrit, MCV, RBC count ratio, reticulocyte count.
IDA will have low Hgb, low MCV, high RDW.
Low retics 2/2 insufficient iron substrate for BM to produce RBCs; microcytic hypochromic Hgb
First to increase will be retics
Most common nutritional deficiency in children, suspect in children taking > 24 oz cow's milk daily
Asymptomatic v fatigue/pallor
Ferrous sulfate with Vit C (increases iron absorption)
Limit intake to < 20 oz daily, increase intake of iron-fortified foods (meat, cereal)
14 y/o F BIB mom for "not having reached puberty" and having "no growth spurt". On exam, pt has mild comedonal acne, breast development maturity stage 3, normal external genitalia and pubic hair is Tanner stage 2. Pt is 25th and 50th %ile for height and weight respectively. Mom says both older sisters had first menses at age 11, and there are "no late bloomers in the family". Best next step in management
Reassurance and observation
Thelarche age 8-12, and menarche 2-2.5 years later (should occur by 15 y/o)
Describe the 4 phases of acetaminophen overdose.
1. Nonspecific symptoms (nausea, GI sx)
2. Clinical improvement, lab abnormalities (rise in LFTs, etc) +/- RUQ pain
3. Hepatotoxic symptoms (lactic acidosis, hypoglycemia, coagulopathy, LFTs > 10,000, elevated bilirubin)
4. Resolution (fulminant liver failure/death or recovery)
Name 2 features of Rett Syndrome.
Developmental regression
Microcephaly
Stereotypic hand movements
Epilepsy
No physical features at birth
4 y/o M BIB mom for refusing to walk since this morning. Pt had right groin pain 2 days ago after T-ball practice, and yesterday mom noticed him "walking funny". Today mom had to carry him here because it "hurt too much to walk", not improved with Tylenol. Of note, pt has had URI symptoms x 2 weeks and is febrile to 101.5. On exam, pt cries on manipulation of right hip and resists passive movement, decreased ROM of right hip. Labs show WBC 14,000 and CRP 4.0 (NL < 3.0). Best next step in management:
A. Antistreptooccal antibody titer
B. Aspiration of hip joint
C. MRI of hip
D. Serum ANA testing
E. Serum Borrelia burgdorferi testing
Aspiration of hip joint
Septic Arthritis in child of UL hip joint
Kocher Criteria: (indicate SA as opposed to transient synovitis
1. non-weight bearing
2. febrile >/= 38.5 (101.3)
3. CRP > 2 or ESR > 40
4. Leukocytosis
>/=3 confers 93% likelihood of septic arthritis
< 3 mos : Staph aureus, GBS, GN bacilli
> 3 mos : Staph aureus, GAS
All ages: Staph aureus > Strep pneumo and Strep pyogenes
4 m/o M BIB dad to clinic for severe diaper rash, not improved with barrier cream with each diaper change. On exam, you see multiple, erythematous, confluent papular lesions at genitalia, buttocks, perineum and genitocrural folds with multiple bright red papules on the inner thigh beyond diaper area. Treatment is:
Clotrimazole cream
17 y/o F p/w right hip and groin pain. She first noticed it 3 mos ago while in scuba class, described as intermittent, aching, attributed to carrying heavy scuba gear, worsened with recent competitive rowing (more intense and constant, occasional "clicking" sensation). Pain is worse with exercise, not relieved with ice or ibuprofen. Pt was adopted from developing country at 18 mos, no known medical hx, lives with parents and cat. BMI 20. VSS. On exam, left pelvis drops when she stands on her right leg. Right hip has decreased abduction. Most likely cause?
Abnormal acetabular development
19 y/o M BIBEMS s/p MVC. Pt was unrestrained driver, confesses to drinking alcohol, denies LOC. BP 150/95, HR 110, respirations shallow and rapid, PERRL. On exam, you see anterior chest wall bruises and peripheral cyanosis. Neck veins are flat, trachea midline. Breath sounds heard symmetrically over both lung fields.
Flail chest
Triad of cafe au lait macules with irregular borders, fibrous dysplasia, and precocious puberty.
McCune Albright Syndrome
14 y/o F with PMH of juvenile myoclonic epilepsy p/w 2 generalized tonic clonic seizures without return to baseline. Parents suspect pt has not taken levetiracetam this week. FSG 115. VS show tachycardia 130, otherwise wnl. On exam, eyes are open but pt not following commands, pupils equal but minimal response to light. Rhythmic non-suppressible twitching of the mouth, both arms and both legs persisted for 10 mins after you gave Ativan 2 mg. Best next step in management.
AEDs (fosphenytoin)
3 y/o F brought into clinic by mom for lump in left axilla x 3 days. Mom tried cold compresses without improvement. Lump is now tender to palpation but has not changed, grown, or given off discharge. Pt attends daycare and has 2 dogs and a kitten at home. VS show temp 100 degrees. Exam remarkable for warm, tender, mobile axillary lymph node, 2 cm. Also small erythematous painless papule on dorsum of 2nd digit of LUE. Multiple superficial linear abrasions on BL forearms. Diagnosis
Cat Scratch Disease
7 y/o M BIB mom for acne and pubic hair. PMH of atopic dermatitis on corticosteroid ointment. No headache vision changes or vomiting. VS WNL. On exam, pubic hair stage 2 sexual maturity, testicles are small without masses. Bone age radiograph consistent with age 9. Diagnosis?
Nonclassic Congenital Adrenal Hyperplasia
excess androgen production 2/2 reduced 21-hydroxylase activity, causing pubic hair growth and acne
Treatment options for ethylene glycol toxicity?
Fomepizole, ethanol, dialysis
Tourette's Syndrome is frequently associated with which 2 psychiatric conditions.
ADHD and OCD
Why is it standard to use high dose amoxicillin for pneumonia and AOM?
strains of resistant strep pneumoniae