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Pediatric Clinical Medicine > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Renal Disease - clinical presentation and labs

A

o Abnormal growth
o Hypertension (HTN)
o Dehydration
o Edema

UA: blood or protein in urine

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2
Q

acute renal failure - clinical presentation

A

altered mental status
nausea/vomiting
malaise

Due to electrolyte imbalance

note: this is also for end-stage chronic renal failure

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3
Q

chronic renal failure

A

hypertension
lab abnormalities (proteinuria, elevated BUN or Cr, anemia, electrolyte abnormalities)
growth failure, rickets
poor feeding

Note: this is when they have not reached end-stage failure yet
- slow process

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4
Q

acute renal failure - pre-renal causes

- including UA and lab findings

A

dec circulating vol: blood loos, dehydration, shock, hearty failure

blocked blood flow to kidneys: thrombi, masses, trauma

UA: inc. Na and H2O reabsorption, conc. urine (high SG), low urine output

Labs: high BUN and Cr (BUN>Cr), low urine Na, high specific gravity

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5
Q

acute renal failure - renal causes

- including UA and lab findings

A

damage to tubules (ischemia, toxins), microvascular injury (HUS), glomerular injury (PSGN, HSP, SLE), or interstitial cell injury (drugs)

UA: high urine Na, urine sediment

Labs: high BUN and Cr (Cr>BUN)

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6
Q

acute renal failure - post-renal causes

- including UA and lab findings

A

anything causing obstruction to urine flow, including anatomical abnormalities or acquire obstructions (renal stones, foreign body, mass, trauma)
- poor urine output

UA: high urine Na, low urine specific gravity

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7
Q

chronic renal failure - causes

A

intrinsic damage (ischemia, toxins), microvascular injury (HUS), glomerular injury (PSGN, HSP, SLE), interstitial injury (drugs)

DM

renal scarring from missed CAKUT

PKD: polycystic kidney disease

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8
Q

end-stage renal disease

A

GFR<15%; requires dialysis and medications (to take the place of hormones the kidney would have produced)

Optimal tx = renal transplantation

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9
Q

HUS - clinical presentation

A

HUS: hemolytic-uremic syndrome

bacterial (E. Coli O:157) cause of ARF (<5y/o) - shiga toxin targets endothelial layer of blood vessels throughout body

  • vomit, bloody diarrhea
  • petechial rash
  • kidney damage and ARF

Triad: microangiopathic hemolytic anemia, thrombocytopenia, renal injury

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10
Q

using creatinine to estimate renal function

A

As renal fx decreases, serum creatinine level rise proportionally
- for every doubling of serum creatinine, the renal clearance (GFR) has been halved

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11
Q

estimate of urinary protein loss using single UA (instead of 24 hrs)

A

Urine Protein/Creatinine Ratio (both expressed in mg/dl)
• <0.2 Normal
• >2.0 Nephrotic range (WU for urinary loss of protein)

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12
Q

renal tubular acidosis: what happens and clinical presentation

A

either insufficient secretion of H+ (type I - permanent) or issue w/ HCO3 reabsorption (type II - kids outgrow by age 4)
- results in metabolic acidosis

Clinical Presentation:

  • growth failure
  • polyuria, dehydration
  • rickets
  • renal stones
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13
Q

renal tubular acidosis - evaluation

A

CMP (included in work-up of a pt w/ growth failure): includes serum bicarbonate, all electrolytes, BUN & Cr

Venous blood gas: lungs should be increasing CO2 excretion in response to the metabolic acidosis

Renal U/S looking for renal stones or hydronephrosis:
• Metabolic acidosis, elevated BUN/Cr, renal stones → refer to nephrology for suspected RTA
• Patients with hydronephrosis → refer to urologist to look for obstructive anomalies

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14
Q

differential diagnosis for red urine

A

trauma, external (perineal or meatus) irritation)

infants: urate crystals in 1st week of life - normal

Pyridium (urinary tract anestetic): causes red urine

rhabdomyolysis: see myoglobinuria due to severe muscle breakdown

renal stones (renal US/abd x-ray)

upper tract bleeding: dark urine, dysmorphic RBCs and cases (nephron level)
- PSGN, IgA nephropathy, HSP, SLE, MPGN

lower tract bleeding: red urine, whole RBCs, no casts (below nephron)
- usually UTI in PEDS

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15
Q

main diseases that cause types of nephritis and resulting hematuria

A

post-streptococcal glomerulonephritis (PSGN)

IgA nephropathy

Henoch-Schonlein purpura

Systemic Lupus Erythematosus

Membranoproliferative glomerulonephritis

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16
Q

post-streptococcal glomerulonephritis (PSGN) - clinical presentation

A

recent URI, sore throat, impetigo
dark urine, edema, HTN, proteinuria
low C3 (transient)

NOTE: most common cause of acute glomerulonephritis (immune-mediated inflammation)

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17
Q

IgA nephropathy - clinical presentation - clinical presentation

A

males, recurrent hematuria (gross - red), possible URI
normal C3

NOTE: most common cause of chronic glomerulonephritis (immune-mediated inflammation)

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18
Q

Henoch-Schonlein purpura - clinical presentation

A

most common form of vasculitis in kids (IgA vasculitis)

palpable purpura
arthritic/jt pain
abdominal pain
renal dz (nephritis = hematuria)

NOTE: if renal involved (hematuria) or HTN –> involved nephrology

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19
Q

Systemic Lupus Erythematosus - clinical presentation

A

hematuria
recurrent/prolonged fever
malar/butterfly rash
arthritic jt sxs

low C3 (active phase - transient)

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20
Q

membranoproliferative glomerulonephritis (MPGN) - clinical presentation

A

looks like PSGN, but does not resolve in 4-6 weeks

hematuria
edema
HTN
proteinuria

low C3 (persistent)

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21
Q

proteinuria: definition and cause

A

abnormal levels of protein in urine (due to glomerular capillary membrane damage by disease)

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22
Q

urine dipstick results and correlation to values for urinary protein loss

A 
Trace or negative is normal
•	1+: 30 mg/dl
•	2+: 100 mg/dl
•	3+: 300 mg/dl
•	4+: 1000 mg/dl
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23
Q

main diseases that cause nephrotic syndrome and resulting proteinuria

A

orthostatic proteinuria

nephrotic syndrome

Nil disease

mesangial nephropathy

focal segmental glomerulosclerosis

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24
Q

orthostatic proteinuria - clinical presentation

A

adolescent / benign
asymptomatic (no edema, no HTN) - occurs w/ activity
- protein/Cr < 2.0
- found incidentally

Note: get F/U first AM UA to verify negative for protein (and get could times in coming yr)

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25
Q

nephrotic syndrome - clinical presentation

A

any age (2-5 yrs)

  • sudden onset of pitting edema or ascites
  • proteinuria (nephrotic range: protein/Cr >2.0)
  • low serum protein (albumin)
  • inc. lipids, inc. clotting, infections

NOTE: most likely dx for proteinuria
- tx w/ Pred - if does not resolve consider chronic dz

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26
Q

Nil disease (minimal change) - clinical presentation

A

idiopathic nephrotic syndrome (< 6yrs)

  • periorbital/pretibial edema
  • proteinuria (nephrotic range: protein/Cr >2.0)
  • low serum protein (albumin)
  • Cr may be low
  • HTN and ascites (+/-)
  • possibly hematuria
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27
Q

mesangial nephropathy - clinical presentation

A

occurs at any age

  • proteinuria (nephrotic range: protein/Cr >2.0)
  • low serum protein (albumin)
  • edema
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28
Q

focal segmental glomerulosclerosis - clinical presentation

A

idiopathic nephrotic syndrome (> 6yrs)

  • proteinuria (nephrotic range: protein/Cr >2.0)
  • low serum protein (albumin)
  • Cr is HIGH
  • significant hematuria
  • HTN
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29
Q

Ddx for peri-orbital edema

A

infection, CHF, renal disorders (nephrotic syndrome - Nil disease)
- MUST get a UA if not clear infection to look at protein or blood

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30
Q

nephrotic syndrome

A

syndrome comprising signs of nephrosis (proteinuria, hypoalbuminemia, and edema)
- loss of protein through the kidneys (proteinuria) leads to low protein levels in the blood (hypoproteinemia including hypoalbuminemia), which causes water to be drawn into soft tissues (edema)

usually managed in primary care and resolves in 2-3 weeks

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31
Q

referral for obstructive uropathy on U/S

A

urologist

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32
Q

referral for renal damage (as indicated by proteinuria and possibly hematuria)

A

nephrologist

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33
Q

blood pressure classification - pediatrics

A

o Normal: <90%
o High: 90-95%
o Significant: 95-99%
o Severe: >99%

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34
Q

BP in PEDS - proper approach to dx of HTN

A

3 BP measurements on 3 separate occasions

  • be sure have right cuff size
  • check staff measurements
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35
Q

primary HTN (essential) in PEDS

A

unlikely unless obese and >12 y/o
- metabolic syndrome = obesity

Note: most common cause of HTN in adolescents

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36
Q

causes of secondary HTN in PEDS

A

Renal causes (70%):

  • renal insufficiency
  • nephrotic syndrome / glomerulonephritis
  • congenital abnormalities
  • structural disorders (Wilms tumor, polycysitc kidney dz)

Vascular causes:

  • coarctation of aorta
  • renal artery embolism or stenosis
  • renal vein thrombosis
  • vasculitis

Endocrine cases:

  • hyperthyroidism
  • pheocromocytoma and neuroblastoma
  • hyperaldosteronism
  • hypercortisolism (Cushings)

Neurologic causes:

  • inc. sympathetic activity (stress, anxiety, pain)
  • inc. ICP

Other:

  • OSA
  • medications
  • illicit drugs
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37
Q

evaluation of pediatric pt with HTN

A

thorough history, ROS, physical exam (focus on secondary causes)

Level 1 work-up: : electrolytes, BUN/Cr, Ca++, thyroid, CBC, U/A + micro, renal U/S
- looks for evidence of renal insufficiency, vasculitis/anemia due to renal disease, renal artery stenosis, and thyroid disorders

  • if results pt to specific dz process: treat or refer
  • if etiology not discovered: contact nephrologist
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38
Q

management of pediatric pt with HTN

A

Asymptomatic stage I HTN w/o end organ damage or systemic disease:
• Step 1: therapeutic lifestyle changes
• Step 2: medication

Symptomatic stage II HTN
• Step 1: medication

Hypertensive emergency: prompt hospitalization (parenteral antihypertensive tx with nicardipine, labetalol, esmolol, sodium nitroprusside)

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39
Q

HTN medications used in PEDS

A

calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, B-blockers, diuretics → more than 1 tx may be needed

  • used as step 2 of asymptomatic and step 1 for symptomatic HTN in peds
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40
Q

urinalysis: macroscopic v. microscopic

A

Macroscopic: uses urine dipstick for pH, presence of protein, glucose, ketones, blood and leukocytes
- Nitrite test may detect bacteriuria if bacteria reduce nitrate to nitrite

Microscopic: confirms pyuria (pus = WBCs), hematuria, casts, crystals

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41
Q

UTI - what is the question you ALWAYS want to ask

A

about un-investigated or un-diagnosed febrile illness

- sign of recurrent UTI

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42
Q

what can chronic NSAID use cause

A

proteinuria (spill protein)

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43
Q

anasarca

A

extreme swelling from nephrotic condition (must go to hospital)
- boys can get a lot of swelling in scrotal area

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44
Q

pediatric UTI - risk factors

A

Age:

  • neonatal uncircumcised boys
  • caucasian girls < 24 mo

Obstructive urological abnormalities:
o vesicoureteral reflux (VUR) obstruction
o ureteropelvic junction (UPJ) obstruction
o posterior urethral valves

Dysfunctional voiding (risk factor; also a cause of VUR)

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45
Q

pediatric UTI - most common organism

A

E. Coli (85%)

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46
Q

pediatric UTI: why so important to dx and tx early

A

Renal scarring: why UTI in children is important to catch early

  • Most common in pts with a hx of recurrent febrile UTI, tx delays >72H, dysfunctional elimination, obstructive uropathies
  • Results in renal insufficiency, hypertension and end-stage renal disease
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47
Q

ABX used for suspected UTI based on hx, PE, and dipstick results (awaiting culture)

A

broad spectrum ABX (cephalosporin - cefixime, cephandir)

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48
Q

UTI: clinical presentation in pediatrics (varies with age)

A

Pre-term, < 3 mo: poor feeding, apnea/bradycardia, lethargy, tachypnea (fever often absent)

Full-term, < 3 mo: fever, poor wt gain, jaundice (conjugated bili – sign of infection), vomiting

<2yr: suprapubic tenderness, fever >102.2 w/o obvious source (>48hrs), fever >104, uncircumcised or w/ hx of UTI

> 2yr: abd pain, enuresis (inability to control urine), back pain, dysuria, frequency, foul smelling urine

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49
Q

pediatric UTI: important history and PE clues

A

Previous UTI or frequent undiagnosed febrile illnesses

Family Hx: UTI, urologic abnormalities

Elevated BP and poor growth - suggest renal insufficiency

Enlarged bladder or kidney(s) - suggest an obstructive uropathy

Bladder/CVA tenderness

External genitalia exam: vulvovaginitis, pinworms, sexual abuse, trauma, STI

Lower back exam → sacral dimples, tufts of hair

50
Q

Febrile UTI - who gets admitted (inpatient) for septic W/U

A

all infants < 2mo

toxic appearing kids

immuno-compromised

unable to tolerate oral meds (vomit)

concern for F/U

not improving after started tx (outpatient)

51
Q

Febrile UTI: outpatient management

A

broad spectrum ABX (cephalosporin): 10 days
- change based on culture results

close F/U

all get imaging (renal U/S, VCUG)

52
Q

uncomplicated cystitis (non-febrile UTI)

A

child > 2 yrs w/ lower tract sxs (dysuria, frequency, urgency, supra public pain) and NO FEVER

53
Q

uncomplicated cystitis: management

A

broad spectrum ABX (cephalosporin): 5-7 days
- change based on culture results

select imaging:

  • < 3 y/o girl 1st UTI
  • all girl w/ recurrent UTI
  • all boys w/ UTI
  • signs of poor growth, hx of urological abnormalities, FH renal dz
54
Q

urinary tract obstruction - typical presentation

A

febrile UTI
hydronephrosis

later in life: renal insufficiency

55
Q

urinary tract obstruction - evaluation

A

renal U/S: right after UTI confirmed w/ c/s

VCUG: sensitive for VUR

Creatinine level: high may indicate UPJ

bladder distention (on palpation): may indicate posterior urethral valves

56
Q

primary nocturnal emesis: definition and causes

A

child never achieved nighttime dryness

Hypotheses: CNS maturational delay, functionally small bladder capacity, decreased response to vasopressin, genetic/more common in boys, sleep disorder (e.g. OSA)

57
Q

secondary nocturnal enuresis: definition and Ddx

A

new onset enuresis after nighttime dryness was achieved for a period of time

Ddx: diabetes mellitus/insipidus, UTI, pinworms, sexual abuse, dysfunctional voiding/elimination syndrome and chronic renal insufficiency

58
Q

nocturnal enuresis - management

A

Urinalysis: all children should have this (at minimum)
- R/O serious secondary causes

Overall: assess commitment of family/patient (tx takes several months)

  • Reward charts for dry nights
  • Bladder training to increase capacity
  • Fluid management: 80% of fluids in a.m. and early afternoon, 20% (and no caffeine) after 5pm
  • Bed wetting alarm: most effective, $50, and 12-16 week commitment
  • Alarm clock for timed voiding: less expensive option
  • DDAVP tablets (vasopressin): highly effective but significant relapse rate after discontinuation
59
Q

dysfunctional voiding - symptoms

A

very common, part of WCC

Sxs: urgency, accidents, and holding maneuvers (most parents do not recognize until asked)
- ask about “potty dance” (post potty-training) and need to go “right away” or will have accident

Later: develop hesitancy, dribbling and straining (lose typical neurologic/anatomical components of micturition)

Highly associated with constipation (30-88%), development of UTI, acquired VUR, and hx of ADHD

60
Q

dysfunctional voiding - work-up

A

Urinalysis: look for infection and proteinuria (evidence of renal damage from constant back-pressure)
- proteinuria: first am urine is best; if positive, follow w/ serum creatinine (renal fx)

Urine culture/screen
Renal US: needed if obstruction is suspected

61
Q

dysfunctional voiding - management

A

Behavior modification (timed voids q 2-3 hrs): wear a timer

Tx of constipation

Urinate prior to urgency

No straining, complete bladder emptying

Avoid caffeine & bubble baths (due to their risk of UTI)

Reward chart for adherence

Note: urology referral may be needed

62
Q

dysfunctional voiding - Ddx

A 
UTI
vesicoureteral reflux (VUR)
vulvovaginits (include pinworms)
adenovirus cystitis (which is hemorrhagic)
STI
urethral strictures
foreign body
sexual abuse
63
Q

cryptorchidism: course, risks, management

A

1 or more of the testes fail to descend into the scrotum; testes not found in scrotum and cannot be manipulated into scrotum by age 6m

course: many descend on own, may need orchiopexy

Risks:

  • ay be indicative of genetic syndrome (examine for dysmorphisms)
  • testicles are at higher risk of cancer; affixing in scrotum allows for frequent pt self-exams

Management:

  • 1st 6 moths: watchful waiting
  • After 6 months: US to determine location, possible orchiopexy
64
Q

retractile testes: course, risks, management

A

testicle may move back and forth between scrotum and groin; common

Course: placing child cross-legged & sitting often allows the testicle to relax into the scrotum

Risks: testicle may be on a short spermatic cord
• Increased stature may result in a testicle that resides in the inguinal canal

Management:

  • noted in the patient’s chronic problem list
  • parents told that son needs exam at his pubertal growth spurt to assess testicular location (in case on short spermatic cord)
65
Q

hydrocele: clinical presentation

A

common, large, sometimes unilateral, swelling to scrotum

- red glow of fluid w/ dark testes on transillumination

66
Q

hydrocele: management

A

Resolve spontaneously by 6 months of age

If not resolved by age 1y, refer to urology

67
Q

balanitis: signs and sxs

A

infected glans of penis (circumcised); associated with poor hygiene or aggressive cleaning with soap

Signs and symptoms:
• Pain, dysuria, penile discharge and the swelling and erythema

68
Q

balanoposthitis: signs and sxs

A

infected glans and foreskin of penis (circumcised); associated with poor hygiene or aggressive cleaning with soap

Signs and symptoms:
• Pain, dysuria, penile discharge and the swelling and erythema

69
Q

fever: causes in developed countries (with vaccines)

A

viral infections: 90%

bacteremia: 1% for vaccinated; 5% for unvaccinated
- meningits, UTI, pneumonia, osteomyelitis, septic joint, cellulitis

other causes:

  • Kawasaki’s
  • Cancer
  • rheumatic dz: JIA, SLE
70
Q

most common serious bacterial infection: relative risk

A

meningitis: most serious (0.5%)
- most serious; N. Meningitides is concern (WBC poor predictor - sneaky

UTI: 2-5% (E. coli most common)
- 1 of 2 most common

Pneumonia: 5%

  • only order CXR in presents of clinical signs
  • 1 of 2 most common

Septic joint, osteomyelitis, cellulitis

71
Q

viral causes of fever that are a concern in infants

A

Varicella and Herpes: risk of disseminated dz
RSV: risk of respiratory compromise (also simultaneous UTI)
Influenza: risk of secondary infections and respiratory compromise

72
Q

pneumonia - clinical signs of LRI

A

tachypnea, cough, inc. WOB (runny nose, abnormal breath sounds)

73
Q

what is common with RSV

A

To also have a UTI causes by bacteria (7%)!

74
Q

fever in child 0-36 months (< 3yrs): Ddx

A

Viral: RSV, croup, varicella, cocksackie, herpetic gingivostomatitis, AOM (low prevalence <3mo)

Bacteremia (2-3%, <0.5% S.pneumoniae)
- Meningitis (0.5%), UTI (2-5+%), pneumonia (5%), septic joint, osteomyelitis, cellulitis

Kawasaki’s

Cancer,

Rheumatological dz (JIA, lupus)

75
Q

fever in child > 3 yrs: Ddx

A

Viral: AOM, RSV, varicella, cocksackie, herpetic gingivostomatitis, croup (less likely)

Bacteremia (2-3%, <0.5% S.pneumoniae)
- Meningitis (0.5%), UTI (2-5+%), pneumonia (5%), septic joint, osteomyelitis, cellulitis

Kawasaki’s

Cancer, Rheumatological dz (JIA, lupus)

76
Q

likelihood of various illnesses being fever source

A

Bacterial gastroenteritis: if hx of diarrhea (esp. w/ blood or mucous) consider this possibility

Rapid influenza test: false positives are frequent, (+) results only helpful if flu season

RSV if cough and inc. WOB (in season): 1.1-7% risk of concomitant SBI (UTI)

Croup, varicella, obvious cocksackie (hand, foot, mouth) or herpetic gingivostomatitis (HSV on gums): unlikely to have concomitant SBI
- feel comfortable that these dx explain the fever

Otitis media: low prevalence in children < 3m/o
- be sure PE matches dx for AOM → many children wrongly dx w/ AOM (missing a SBI)

77
Q

causes of prolonged fever

- viral causes typically last 3-5 days

A

SBI that has not been located: do a CRP / ESR

CMV, EBV: common culprits of prolonged fever (important tests in primary care)

Tuberculosis
Lymphoma and Leukemia
Juvenile Idiopathic Arthritis
Endocarditis
Malaria
Hyperthyroidism
Kawasaki’s disease
 - FWS may be only sx in infants
78
Q

what MUST you do before giving empiric ABX for child with fever W/O source

A

get a lumbar puncture - once begin ABX, results will not be accurate and may be difficult to know what bacteria is present and how to treat

79
Q

what additional test many be helpful to determine low v. high risk in infants w fever W/O source: age 29 to 60/90 days

A

rapid viral testing (nasal wash with PCR) to look for RSV, flu, etc.
- may help to avoid invasive testing (lumbar puncture)

80
Q

low risk criteria for bacteremia (used in children >29 days old)

A 
WBC normal
Bands: no “left shift”
U/A normal
CSF (if obtained) <8 wbc/hpf
CXR negative (pneumonia)
Stool gram stain <5wbc/hpf (if obtained; bacterial gastroenteritis)
Inflammatory markers (CRP and  PCT)

Note: also consider rapid nasal wash viral testing

81
Q

best lab tet predictor of serious bacterial infection (SBI)

A

Inflammatory markers (CRP and PCT (procalcitonin)): if both are positive, best predictor of SBI (compared to WBC or band count)

82
Q

ill child - clinical signs

A 
lethargy
poor perfusion (general color, capillary refill, turgor, blood pressure)
very slow or very fast breathing
cyanosis
abnormal cry

Young children who are hypothermic (<37C), esp. neonates who may not mount febrile response

83
Q

ill child - management

A

regardless of fever, children who appear ill need admit to hospital for stabilization, complete SWU, empiric IV ABX (LP first!) pending culture results

84
Q

Kawasaki Disease - signs and sxs

A

cause: unknown (likely viral)
- cardiac complications

Pronged fever (> 5d): may be only sxs; consider Kawasaki if…

  • Infants < 6 mo with FWS > 7 d
  • All children with FWS > 5 ds and 2-3 sxs of Kawasaki’s:

Non-exudative conjunctivitis
Cracking, fissuring of lips, oral mucosa
Unilateral cervical lymphadenopathy
Non-specific rash to trunk, extremities
Palmar/solar erythema & edema followed by peeling
Arthralgia: non-verbal child shows refusal to walk or crawl

85
Q

whimpering

A

sign of serious illness (meningitis) in neonate / young infant
- crying increases ICP so avoid due to pain

86
Q

pearl: test for very sick neonate / infant

A

pull on extremities - even neonate will pull back unless very sick with sepsis or meningitis

87
Q

WBC differential - sign of bacterial infection

A

increase in band (left shift): body sending immature WBCs into periphery to fight bacterial infection

88
Q

WBC differential - sign of viral infection

A

increase in lymphocytes

89
Q

hydration status in neonates / young infants

A

Sternal cap refill is best (central perfusion)

Depressed fontanels and skin turgor (tenting) are late signs (severe dehydration)

90
Q

juvenile idiopathic arthritis: definition

A

autoimmune disease that targets that synovial joints, resulting in inflammation with synovial tissue hypertrophy and increased amounts of joint fluid
- often FH of autoimmune disease

91
Q

juvenile idiopathic arthritis: diagnostic criteria

A

Age of onset < 16 years

Arthritis in 1+ joints
• Arthritis: joint swelling or effusion OR presence of 2 or more of → limited ROM, tenderness or pain with motion, and warmth

Duration of disease ≥ 6 weeks

92
Q

arthritis

A

joint swelling or effusion OR presence of 2 or more of → limited ROM, tenderness or pain with motion, and warmth

93
Q

systemic JIA: sxs, exam findings, complications

A

Symptoms (girls/boy equal):

  • polyarticular arthritis, affects both small and large jts
  • brief fever (>39C) 1-2 times daily (afternoon/evening)
  • fever accompanied by Still’s rash

Exam findings:
- hepatosplenomegaly, LAD, serositis, hepatitis and tenosynovitis

Complications:
- serositis, tenosynovitis

94
Q

serositis

A

inflammation of the serous tissues of the body (tissues lining the lungs (pleura), heart (pericardium), and the inner lining of the abdomen (peritoneum) and organs within)
- can see on CXR (fluid)

95
Q

tenosynovitis

A

inflammation of the lining of the sheath that surrounds a tendon

96
Q

oligo JIA: sxs, exam findings, complications

A

Symptoms (girls more common):
- arthritis in < 4 joints, larger joints, asymmetrical

Exam

  • Leg discrepancy (faster growth in affected limb)
  • Often keep leg flexed
  • Muscle atrophy in area

Complications:
- uveitis

97
Q

poly JIA: types, sxs, exam findings, complications

A

Types:

  • Rheumatoid factor negative: not associated with more destructive pattern
  • Rheumatoid factor positive: associated w/ rheumatoid nodules, chronic arthritis, and joint destruction

Symptoms (most common girls, RF):

  • involves > 5 joints, both large and small joints affected in a symmetric pattern
  • fatigue, anemia of chronic dz, growth failure

Exam: RF (possibly positive), synovitis, rheumatoid nodules (large bumps)

Complications: destructive pattern seen with RF+

98
Q

spondyloarthropathies
- ankylosing spondylitis

Sxs, exam findings, complications

A

Symptoms:

  • Male predominance of 6:1, onset in late childhood/early adolescence
  • Begins w/ peripheral arthritis (enthesitis - inflammation at insertion of tendons), and later moves axial/central involvement

Exam:
- RF and ANA are negative, HLA-B27 is + in 90% of pts, often a positive family history

Complications:
- inflammatory manifestations outside the joints: uveitis, aortic valve insufficiency

99
Q

painful joint Ddx

A

acute trauma

transient synovitis / reactive arthritis

bacterial infections: septic arthritis, osteomyelitis, sepsis

viral infections: parvovirus, EBV, reactive arthritis

malignancy: leukemia, neuroblastoma

rheumatic dz: SLE, HSP, vasculitis

growing pains

100
Q

key rheumatology concern questions

A

When does pain occur: pain in the morning and after naps is suggestive of inflammatory process

Will child let you touch / massage jt: typically, kids do not like inflamed joints (due to systemic arthritis) touched
- versus growing pains that get better with massage

101
Q

reactive arthritis: clinical presentation and lab/imaging findings

A

umbrella term which includes transient synovitis (hip only)

Clinical:

  • acute onset, well appearing, difficulty wt bearing (if hip, knee, ankle), limp, limited internal rotation of affected side (hip)
  • common after a viral illness

Lab/imaging: none

102
Q

septic arthritis: clinical presentation and lab/imaging findings

A

Clinical:
- rapid onset of limp / refusal to wt bear in an ill-appearing child, fever, affected leg held rigidly, major resistance to any ROM

Lab/imaging: YES!

  • X-ray/US: widened jt space
  • CBC: high WBC w/ lt shift
  • ESR and CRP elevated
  • Blood culture (obtain!):
  • Joint aspiration w/ cell count, gram stain, and culture
103
Q

systemic lupus erythematosus (SLE): definition and pathology

A

auto-immune disease
multi-system
pts have variety of sxs that come and go
- remission and exacerbation

pathology:
- inflammation, vasculitis (swollen), immune complex deposition, and vasculopathies
- complement-consuming disease (low C3 during exacerbations)

104
Q

systemic lupus erythematosus (SLE): presentation (including dx criteria)

A

multi-system disease, sxs come and go

Diagnostic criteria (4+ for dx):

  • malar rash: “butterfly rash” on cheeks and nose
  • discoid rash: raised, red patches with scaling and plugging of hair follicles (rare in PEDS)
  • photosensitivity: caused by sun
  • oral/nasal ulcerations: usually hard palate of mouth or nasal septum
  • serositis
  • arthritis: involves 2+ peripheral jts
  • nephritis
  • CNS disease: seizures, psychosis, strokes, chorea, headaches, pseudotumor and depression/anxiety (not diagnostic)
  • heme abnormalities: hemolytic anemia, leukopenia, thrombocytopenia
  • ANA positive
  • positive SLE serologies
105
Q

systemic lupus erythematosus (SLE): laboratory eval (before and after diagnosis)

A

Initial:

  • CBC and U/A with microscopy (tests that look for criteria for dx)
  • consult pediatric rheumatologist: prior to ordering ANA titer or SLE-specific serologies

After Dx:

  • CBC, ESR, UA, double-stranded DNA, and complement (C3,C4)
  • used to monitor disease activity and drug side effects
106
Q

systemic lupus erythematosus (SLE): complications

A

infection: leading cause of death (low complement)

GI bleeding, MI, malignancy

renal disease: transplant and dialysis have made this manageable

osteoporosis, infertility and psychosocial impairment

107
Q

systemic lupus erythematosus (SLE): epidemiology

A

females > males

peak onset in late adolescence / young adult (sex hormones may play role)
- OCP / pregnancy

African ancestry > Asian > Latino > Caucasians

cause unknown: 10% have FH and 13% have another autoimmune disorder

108
Q

5 hospital maternity care practices to improve breastfeeding success

A

o 1. Infants are breastfed in the first hour after birth.
o 2. Infants stay in the same room as their mothers.
o 3. Infants are fed only breast milk and receive no supplementation.
o 4. No pacifier is used.
o 5. Staff gives mothers a telephone number to call for help with breastfeeding.

109
Q

WHO recommendations for breastfeeding

A

exclusively breastfed for 6 mo
continue breastfeeding, with the introduction of appropriate complimentary foods
continue through the second year of life and beyond

110
Q

two major things breastmilk has that formula does not

A

Enhance the immune system (colostrum, secretory IgA (special antibody), enzymes, WBCs, and other immune components

Promote optimal brain development

111
Q

benefits of breastmilk - general

A

species-specific (bioavailable)

reduce risk of disease in baby: DM, SIDS, IBD, atopy

Protect against diarrhea and ear infections

reduce risk of childhood obesity: baby led amounts; hormones (leptin and gherlin) associated with satiety long-term prevention of obesity

maternal / infant bonding

maternal bebefits: weight loss, lowers risk of breast and ovarian cancers, convenience, calming benefits

112
Q

vitamins lacking in breastmilk

A

vitamins K and D

113
Q

contraindications for breastfeeding

A

galactosemia: genetic metabolic disorder where baby cannot digest galactose

PKU: lack enzyme needed to breakdown protein phenylalanine
- proceed with caution

CF: need supplemental pancreatic enzymes

114
Q

HIV: recommendations for breastfeeding in US

A

AAP recommends no breastfeeding for women living in US (can be transmitted through breast milk)

115
Q

TB: recommendations for breastfeeding in US

A

no breastfeeding if dx w/ active pulmonary TB, tx has not started, or on tx for < 2wks
• Airborne transmission necessitates separation of mother and infant
• TB is not transmitted through milk (mom can pump and store)
• IHN prophylaxis for all infants whose mothers have been dx w/ active pulm TB postpartum

116
Q

nutritional parameters for breastfeeding newborns - rules of 5’s and 10’s

A
  1. Weight loss (up to 10%)
  2. Regain birth weight by DOL 10, gaining approx. 20-30 grams/day
  3. Colostrum: a teaspoon (5ml) at a good feed on DOL 1-2, about 40-50 ml (1-2 oz) in the first 24 hrs (8-10 feeds)
  4. Yellow stools by Day 5
117
Q

frequency of breastfeeding newborn in 24 hours

A

10-12 is ideal (minimum of 8 times)

118
Q

newborn early hunger cues

A

rooting, hands to mouth, mouthing moments, waking up, fists clenched

119
Q

3 good areas of education before mom leaves hospital

A

nutritional parameters
hand expression (engorgement / stimulates production)
asymmetrical latch and positioning

120
Q

reasons for low milk supply

A 
Stress, dehydration, obesity, PCOS
Sheehan’s Syndrome: pituitary hemorrhage
Retained placenta
Hypothyroidism
Medications (high estrogen birth control, etc.)

Pediatric Clinical Medicine (4 decks)

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