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Features of an infant with failure to thrive
Low weight, normal length and head circumference
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Criteria for failure to thrive
Growth below 5th percentile or crossing two major growth percentiles in a short time
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Broad causes of inadequate weight gain (4)
- 1. Inadequate caloric intake
- 2. Altered growth potential
- 3. Caloric wasting
- 4. Increased caloric requirements
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Causes of inadequate caloric intake (3)
- 1. Lack of appetite due to depression or chronic disease
- 2. Difficulty of ingestion - feeding disorder, cerebral palsy, facial abnormality, tracheoesophageal fistula
- 3. Food not available
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Causes of altered growth potential in infancy (3)
- 1. Prenatal insult
- 2. Chromosomal abnormality
- 3. Endocrine disorder
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Causes of caloric wasting (3)
- 1. Emesis due to GI disorder, toxin, or CNS pathology
- 2. Malabsorption due to GI disorder, infection, or toxin
- 3. Renal loss due to DM or tubular acidosis
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Causes of increase in caloric requirements (2)
- 1. Increased metabolism
- 2. Defective use of calories
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Causes of increased metabolism in infants (5)
- 1. Congenital heart disease
- 2. Chronic respiratory disease
- 3. Neoplasm
- 4. Chronic infection
- 5. Hyperthyroidism
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Causes of defective use of calories in infants (2)
- 1. Metabolic disorder
- 2. Renal tubular acidosis
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Laboratory tests in failure to thrive (7)
- 1. CBC
- 2. Lead level
- 3. Calcium
- 4. BUN
- 5. Creatinine
- 6. TB test (maybe)
- 7. HIV test (maybe)
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Calories required by an infant in the first year of life
120 kCal per kg per day
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Calories required by an infant after the first year of life
100 kCal per kg per day
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By what percentage should caloric intake be increased in an infant to treat failure to thrive?
50-100%
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Retention of EtOH in urine for screening
10-13h
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Retention of EtOH in blood for screening
7-10h
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Retention of marijuana in urine for screening
- 3-10d (occasional users)
- 2mo (chronic users)
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Retention of cocaine in urine for screening
2-4d
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Retention of methamphetamines or Ecstasy in urine for screening
2d
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Retention of opiates in urine for screening
2d
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Retention of PCP in urine for screening
8d
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Retention of barbiturates in urine for screening
- 1d (short-acting)
- 2-3wk (long-acting)
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Drug causing pupillary dilation
Cocaine
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Drugs causing pupillary constriction (2)
- 1. Opiates
- 2. Barbiturates
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Drug causing hypersalivation
PCP
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Maternal age and Down Syndrome
Increased rate of DS for each year after age 35
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Bradydactyly
Shortened tubular bones of hands and feet. Sign of Down Syndrome
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Clinodactyly
Inward curving of a digit. Clinodactyly of the 5th digit is a sign of Down Syndrome
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VATER Symptoms
- Vertebral problems
- Anal anomalies
- Trachea problems
- Esophageal abnormalities
- Renal abnormalities
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Maternal blood screening results in Trisomy 21 (3)
- 1. Low alpha-fetoprotein
- 2. High hCG
- 3. Low estriol
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Physical signs of Down Syndrome (12)
- 1. Upslanting palpebral fissures
- 2. Brushfield spots (in the iris)
- 3. Flat facial profile
- 4. Small, rounded ears
- 5. Excess nuchal skin
- 6. Widespread nipples
- 7. Pelvic dysplasia
- 8. Hyperflexible joints
- 9. Simian crease
- 10. Hypotonia
- 11. Clinodactyly of 5th finger
- 12. Poor Moro reflex
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Cardiac defects common in Down Syndrome (3)
- 1. Endocardial cushion defect (most common)
- 2. VSD
- 3. Tetralogy of Fallot
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GI defects common in Down Syndrome
Intestinal atresia (especially duodenal atresia). May present with polyhydramnios.
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Ocular and auricular defects common in DS (4)
- 1. Hearing loss
- 2. Strabismus
- 3. Cataracts
- 4. Nystagmus
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Endocrine defect common in Down Syndrome
Hypothyroidism
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Tetralogy of Fallot (4)
- 1. Pulmonary stenosis
- 2. Overriding aorta
- 3. VSD
- 4. RVH
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Features common in Edwards Syndrome
- 1. Weak cry
- 2. Single umbilical artery
- 3. Micrognathia (small mouth, high arched palate)
- 4. Clenched hand (2nd finger overlaps the 3rd finger)
- 5. Simian crease
- 6. Rocker-bottom feet
- 7. Small pelvis
- 8. Short sternum
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Genetic cause of Edwards Syndrome
Trisomy 18
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Features of Patau Syndrome (9)
- 1. Microcephaly with sloping forehead
- 2. Deafness
- 3. Scalp cutis aplasia
- 4. Microphthalmia
- 5. Coloboma
- 6. VSD
- 7. Omphalocele
- 8. Single umbilical artery
- 9. Hypersensitive to atropine and pilocarpine
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Genetic cause of Patau Syndrome
Trisomy 13
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Signs and symptoms of meningitis in an infant
- 1. Inconsolable crying; worse when picked up (paradoxical irritability)
- 2. Altered mental status
- 3. High fever
- 4. Bulging fontanelle
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Signs and symptoms of meningitis found in older children, but often absent in infants (4)
- 1. Nuchal rigidity
- 2. Photophobia
- 3. Kernig / Brudzinski signs
- 4. Headache
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Common causes of meningitis in neonates (5)
- 1. Group B strep
- 2. Gram negative rods (especially E. Coli)
- 3. S. Pneumoniae
- 4. Listeria
- 5. N. Meningiditis
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Common causes of meningitis in non-neonates (2)
- 1. Coxsackievirus
- 2. Echovirus
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CSF in viral meningitis (4)
- 1. elevated WBCs, but below 1,000 per hpf
- 2. < 50% PMNs
- 3. normal glucose
- 4. normal protein
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CSF in bacterial meningitis (4)
- 1. >1,000 WBCs per hpf
- 2. >90% PMNs
- 3. Glucose < 20
- 4. Protein > 100
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Empiric treatment of bacterial meningitis (2)
- 1. Gentamycin
- 2. Ampicillin
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Treatment of bacterial meningitis in non-neonates (3)
- 1. IV penicillin
- 2. 3rd-generation cephalosporins (if PCN-resistant)
- 3. Vancomycin
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Common complication of meningitis in neonates
SIADH
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Sepsis
Clinical signs due to inflammatory response; often leads to changes in organ function
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Clinical findings in sepsis (5)
- 1. Hypo or hyperthermia
- 2. Hypotension with wide pulse pressure (diastolic less than 1/2 of systolic)
- 3. Tachycardia
- 4. Increased respiratory rate (due to metabolic acidosis)
- 5. Altered mental status
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Lab values in sepsis
- 1. Increased WBCs with left shift
- 2. Reduced platelets (due to DIC)
- 3. Reduced hemoglobin and hematocrit (due to hemolysis and marrow suppression)
- 4. Reduced HCO3 and CO2 (ion gap acidosis)
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Infections causing sepsis in neonates (4)
- 1. Listeria
- 2. GNRs
- 3. Group B strep
- 4. Herpes simplex virus
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Infections causing sepsis in non-neonates (2)
- 1. S. Pneumoniae
- 2. N. Meningitidis
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Supportive treatments for sepsis (3)
- 1. Maintain airway and give O2
- 2. Give fluids: 20 mL/kg by IV or intraosseous injection per bolus
- 3. Give pressors if 2-3 boluses of fluids do not raise BP enough
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Antibiotics used in sepsis (4)
- 1. Ampicillin (drug of choice)
- 2. Penicillin G
- 3. 3rd generation cephalosporins
- 4. Gentamycin
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Bone alignment in a septic hip
Hip is flexed, externally rotated, and abducted
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Lab values in a septic joint (4)
- 1. Increased sed rate
- 2. Cloudy joint fluid
- 3. > 50,000 WBCs per HPF in joint fluid
- 4. Positive culture of joint fluid 50-60% of the time
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Bacteria of septic joints in neonates (3)
- 1. E. Coli
- 2. Listeria
- 3. Group B Strep
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Bacteria of septic joints in non-neonates (2)
- 1. S. Aureus
- 2. S. Pneumoneae
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Septic joint vs. synovitis on physical exam
Synovitis has no erythema or appreciable swelling
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Lab values in synovitis (4)
- 1. Normal to slightly high sed rate
- 2. Normal to slightly high WBCs
- 3. Clear-to-cloudy joint fluid
- 4. < 50,000 WBCs per HPF in joint fluid
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Course of synovitis
2/3 to 3/4 resolve spontaneously within 2 weeks
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Leg-Calve-Perth's Disease
Ischemic necrosis of the femoral head, leading to collapse of the femoral head
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Leg-Calve-Perth's Disease on physical exam (3)
- 1. Painless limp
- 2. Pain in groin, knee, and thigh with external rotation or abduction of the hip
- 3. Discrepancy in leg lengths
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Treatment of Leg-Calve-Perth's Disease
NSAIDs and activity restriction
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Slipped Capital Femoral Epiphysis (SCFE)
Slippage of the epiphysis from the femur due to high stress to the hip
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Symptoms of SCFE
- Dull, achy pain for > 3 months
- Found deep in the groin and may refer to leg and thigh
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SCFE on physical exam (4)
- 1. Pain when walking
- 2. Reduced internal rotation
- 3. Reduced flexion
- 4. Atrophy of the thigh
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Treatment of SCFE
Surgical placement of pins
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Presentation of growing pains
Pain in long bones, not joints, lasting > 3mo. May awaken from sleep
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Presentation of Osgoode-Schlatter
Pain at tibial tuberosity, at the patellar insertion; occurs in active and growing children
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