For kids being treated for hypothyroidism, what would cause both TSH and fT4 to be elevated?
Not taking thyroid hormone (as directed); disconcordance between thyroxine and TSH suppression causes elevated TSH (missed a dose) and then elevated fT4 (extra synthroid was taken)
Target pattern lesions in the form of erythematous papules or plaques with central VIOLACEOUS discoloration; no mucosal involvement - diagnosis?
Prodrome of fever, headache, malaise, cough, sore throat x1-14 days followed by eruption of nontargetoid erythematous or violaceous macules/patches that blister and rupture; mucosal involvement at conjunctiva, mouth, urethra, and rectum - diagnosis?
Stevens-Johnson syndrome or toxic epidermal necrolysis
What is the difference between SJS and TEN?
Less than 10% epidermal loss is SJS
10-30% epidermal loss is TEM
Neonate with h/o IUGR, microcephaly, seizures, hepatopathy, bone marrow suppression should make you think of what diagnosis?
TORCH infection (in utero infection)
What TORCH stand for?
2) Other (Syphillis, VZV, parvovirus, HIV)
5) Herpes simplex virus
What is the risk of transmission of HIV to an infant from an infected mother who breastfeeds?
Approximately 20% to 45%
What category of bacteria does pseudomonas sp. fall under?
In a sick patient (i.e. cystic fibrosis) with suspected pseudomonal sepsis, what is first line empiric therapy?
1) 2 antipseudomonal agents
Name 3 beta-lactams that are effective against pseudomonas?
3) Pipericillin +/- tazobactam
Furosemide usage leads to urinary loss of what 3 electrolytes?
How does furosemide work?
Blocks Na+/K+/2Cl- transporter in the loop of Henle
How does furosemide cause sensorineural hearing loss?
Inhibition of the Na+/K+/2Cl- transporters in marginal cells of cochlear duct of inner ear leads to reduced endocochlear potentials
How does chronic furosemide increase risk for kidney stones?
In a person with history of allergy to beta-lactams, which cephalosporin is MOST likely to elicit cross-reaction?
First generation cephalosporins
(T/F) Negative skin testing to major (penicilloyl) and minor (penicilloate) determinants of penicillin can exclude almost all IgE-mediated reactions to penicillins
What is the best thing you can do for a person with an avulsed tooth?
Reimplant tooth gently back into socket and have the patient hold in place during transport
What are good liquid solutions for preservation of an avulsed tooth?
1) Balanced salt solution
3) Saliva (in buccal vestibule)
Neonatal lupus erythematosis is caused by transplacental passage of what 3 maternal antibodies?
1) Anti-Ro (SSA)
2) Anti-La (SSB)
3) Anti-U1 RNP
What do the skin lesions of neonatal lupus erythematosis (NLE) look like?
Erythematous annular plaques located in sun-exposed areas (face)
What is the initial work-up for an infant with neonatal lupus erythematosis? (3)
1) EKG: evaluate heart block
2) CBC: eval heme issues
3) LFT: eval for hepatopathy
Early-onset (neonatal) GBS infection occurs within what time frame?
First 24 hours of life
Late-onset (neonatal) GBS infection occurs within what time frame?
First 7 days of life
What are 4 clinical manifestations of early-onset GBS infection?
2) Pulmonary hypertension
3) Septic shock
4) Meningitis (<10%)
What are 3 manifestations of late-onset GBS (that are less likely in early-onset GBS)?
3) Septic arthritis
How does GBS bacteremia cause pulmonary hypertension?
GBS toxin can mediate pulmonary vascular constriction
Hypertensive crisis should be suspected in the face of markedly elevated BP PLUS any of the 3 following clinical manifestations:
1) CNS symptoms (HA, vision changes, seizure)
3) Congestive heart failure (HSM, pulm edema)
What are 3 likely causes of hypertensive crisis?
1) Drug ingestion (sympathomimetics)
2) Renal disease
3) Unrecognized progressive hypertension
For all women capable of becoming pregnant, what is the CDC's recommendation for prevention of neural tube defects?
0.4 mg of folic acid daily
For women who had a previous pregnancy affected by neural tube defect, what is the CDC's recommendation for prevention of future neural tube defects?
4 mg folic acid daily from time of trying to get pregnant through first trimester
(T/F) Research indicates that adolescents are more likely to disclose sensitive information if clinicians make explicit statements about confidentiality.
(T/F) State laws mandate that adolescents in all states may receive confidential treatment for alcohol and other drugs.
False - state laws vary in extent to which they protect confidentiality of minors; can't cover every situation
(T/F) Billing policies of an outpatient or inpatient facility are always confidential in regard to STI testing in adolescents.
False - EMR may not always have safeguards for confidentiality
What are the 3 most common side effects of methimazole and propylthiouracil?
What are rare but serious side effects of methimazole and propylthiouracil?
4) Vasculitis (more for PTU)
What 3 treatment options for people with hyperthyroidism?
1) Antithyroid medication
2) Ablative therapy with radioactive iodine
3) Surgical thyroidectomy
Regarding treatment of skin abscesses, beyond what size do most experts recommend starting antibiotics?
5 cm or greater (start abx after I & D)
What is recurrent (functional) abdominal pain syndrome?
Unexplained abdominal pain severe enough to interfere with school; can be precipitated by stress
What does the palpation of a prominent precordial lift indicate?
Right heart volume overload
Loud systolic ejection murmur over LUSB indicates what heart lesion?
What are antibiotic choices for outpatient treatment of Lyme disease?
Less than 8 yo: doxycycline
8 yo and older: amoxicillin
What are antibiotic choices for inpatient treatment of Lyme disease?
Ceftriaxone or penicillin
What are 3 indications for parenteral antibiotics for Lyme disease?
1) Persistent/recurrent arthritis after trial of oral abx
What are beta-lactamases?
Enzymes produced by gram-negative bacilli that hydrolyze beta-lactam ring
Extended spectrum beta-lactamases (ESBL) confer resistance to which 4 antibiotics?
1) 3rd gen cephalosporins
2) Monobactam (aztreonam)
Which organisms typically develop ESBL?
1) Klebsiella sp
2) E. Coli
3) Proteus mirabilis
4) Pseudamonas sp
What is the study of choice to evaluate for UPJ obstruction?
MAG-3 radioisotope scan - shows delayed "washout" with lasix infusion
What is the study of choice to evaluate for duplex collecting system with ureterocele?
VCUG - filling defect in bladder
What are 6 clinical manifestations of Jimson weed exposure?
1) Bizarre behavior
4) Dry skin
6) Dilated pupils
What are 2 clinical features of hand-foot-and-mouth disease?
1) Cutaneous findings: erythematous papule/vesicle on palms or soles
2) Oral-mucosal findings: ulcers on soft palate, uvula, tonsillar pillars and tongue
What are clinical features of herpangina?
Ulcers or vesicles in posterior pharynx including: tonsillar pillara, soft palate, uvula
In a term infant, when does physiologic anemia occur?
6 weeks to 3 months (you can reassure parents that anemia will resolve by 4 months)
In preterm infants, when does "physiologic" anemia occur?
As early as 3-6 weeks
In term infants, how low does hemoglobin get at nadir?
Usually no less than 9 g/dl
In preterm infants, how low does hemoglobin get at nadir?
Down to 7 g/dl
Normal MCV in kids 6 month and older?
What are the 5 major Jones criteria for the diagnosis of rheumatic fever?
2) Erythema marginatum
3) Syndenham chorea
5) Subcutaneous nodules
What are the 4 minor Jones criteria for the diagnosis of rheumatic fever?
3) Acute phase reactants up
4) Prolonged PR interval
What counts as evidence of prior GABHS infection? (2)
1) Throat culture+
2) Rising ASO titer
How do you make the diagnosis of rheumatic fever?
1) 2 major Jones criteria
2) 1 major + 2 minor Jones criteria PLUS evidence of past GABHS infection
What is the number 1 cause of death in teenagers?
Motor vehicle crash
For a child with first-time unprovoked seizure, what is his recurrence risk in the next 12 months if he is otherwise healthy?
1 in 3
For a child with first-time unprovoked seizure, what is his recurrence risk in the next 5 years if he has a history of developmental delay, MR, CP, or other CNS problem?
What the 3 key factors in preventing/delaying complications of diabetes?
1) Glycemic control
2) Blood pressure control
3) Smoking cessation
Yersinia enterolytica infection is associated with meat product?
Escherichia coli O157:H7 infection is associated with meat product?
Which diarrheal pathogen is associated with consumption of raw seafood, ice, salads, and cruise ships?
Norovirus (Norwalk virus or Norwalk-like virus)
What differentiates adenoviral diarrhea from rotaviral diarrhea?
Adenovirus associated with ingestion of contaminated foods, while rotavirus is not (both occur in kids <4yo)
How long does it take to develop diarrhea from ingesting food contaminated with Staph aureus or Bacillus cereus?
1 to 8 hours (FAST ONSET!); other pathogens take days to develop symptoms
What is the MOST common explanation for a palpable abdominal mass in a newborn?
Multicystic dysplastic kidney
Using the 4 clinical features of describing asthma severity, what are the cut-offs for diagnosing persistent asthma?
Daytime symptoms >2 times/wk
Nighttime symptoms >2 times/mo
Peak flow variability >20%
For infant CPR, which method of chest compressions is superior: 2 thumb-encircling hands technique or 2 fingers on sternum technique?
2 thumbs-encircling hands technique
What is the depth you should achieve for chest compressions on an infant?
One third to half the AP diameter
When do you need to pause between breaths and chest compressions?
When definitive airway has not been established - 15:2 for 2 person CPR, 30:2 for 1 person CPR
Why is it important to allow full chest recoil after each compression in CPR?
To enable cardiac refilling
What is the treatment for labial adhesions?
Estrogen cream (followed by zinc oxide paste or petrolatum)
What level of direct (conjugated) bilirubin do you consider cholestasis or biliary obstruction?
2 mg/dl or 20% of TSB
The following should make you think of what diagnosis?
-Posterior iris embryotoxin
-Peripheral pulmonic stenosis
-Big forehead, pointed chin, hypertelorism
What is the most common brachial plexus palsy in newborns?
Which palsy affects the upper arm?
Which palsy affects the lower arm?
Which brachial plexus palsy has poorer prognosis?
Klumpke palsy - affecting lower arm
Aside from arm weakness, what are 3 other clinical manifestations of brachial plexus palsy?
1) Diaphragmatic weakness
2) Shoulder drop
3) Horner syndrome
For brachial plexus palsy isolated to the arm, what is he mainstay of management?
1) Occupational therapy
2) Physical therapy
3) Surgical repair for severe
(T/F) Hemolysis due to ABO or Rh incompatibility can persist for weeks?
True - maternal IgG has a long half-life
What is the main cause of "intoeing" during early infancy?
Metatarsus adductus: incurving of the forefoot
What is the main cause of "intoeing" during toddlerhood?
What is the main cause of "intoeing" during early childhood?
What are clinical signs of femoral anteversion?
1) Reduced external hip rotation
2) Sitting in the "W"'position"
What are classic findings on radiograph that would suggest Blout disease?
Downsloping of the medial metaphysis of the proximal tibiae (leading to bowed legs)
Late systolic ejection murmur heard best at the apex in a tall teenager - what's the heart lesion?
Mitral valve prolapse
Ejection click best heard at the right upper sternal border - what's the heart lesion?
Aortic valve stenosis
What is the first-line anti-seizure medicine is used for treatment of partial epilepsy?
Carbemazepine or valproic acid
What is the first-line anti-seizure medicine is used for treatment of generalized primary absence seizure?
Ethosuximide or valproic acid
What is the first-line anti-seizure medicine is used for treatment of status epilepticus?
1) Diazepam to abort seizure
2) Phenobarbital or phenytoin for maintenance
Why should power lifting and body building be discouraged in children and young teens?
To prevent injury to an immature skeleton
Poor weight gain (or weight loss) in a kid with adequately controlled diabetes mellitus type 1 should make you think of what diagnosis?
Celiac disease (DM1 has higher risk for autoimmune disease)
Poor weight gain (or weight loss) is a kid with POORLY controlled diabetes mellitus type 1 should make you think of what 2 diagnoses?
1) Mauriac syndrome (associated with hepatomegay and very high glucose concentrations; HgbA1c 12-14%)
2) Diabetic ketoacidosis (in the setting of acidosis)
When should a child be starting to sleep through the night?
How can parents promote better nighttime sleeping for their infant? (3)