pediatrics

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pediatrics
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  1. Fever Without a Source (FWS):
    • Children with fever lasting 1 w or less without adequate explanation after a through Hx and P/E.
    • FWLS- fever without localizing signs synonymous
  2. Fever of Unknown Origin (FUO)
    • 7 days or > without source despite W/U
    • Bacteremia
    • Bacteria in the blood
    • Typically found on Blood C+S
  3. Septicemia
    invasion of the bloodstream by virulent microorganisms and especially bacteria along with their toxins from a local seat of infection accompanied especially by chills, fever, and prostration
  4. Fever in infants <3 months things to consider
    • Mother history of fever
    • Mom’s Group B strep status
    • Prophylaxis
    • Mom’s STI hx
    • Hx PROM
    • ill contacts
    • immunization+/-
    • bulging fontanel
  5. workup in fever less than 3 months
    • CBC, WBC < 15,000 (reassuring)
    • Absence of bandemia (reassuring)
    • Blood C+S
    • Preliminary results in 24 h.
    • Procalcitonin/C-Reactive protein
    • U/A and C+S, Stool C+S
    • If blood, mucous or diarrhea is present
    • Lumbar puncture, Age 28 days or less
    • Ill appearing, High risk for bacterial infection
    • Prior to Abx therapy
    • S/S of dz, Sz
    • CXR
  6. empiric trmt in <28 day old SBI
    • ampicillin/ cefotaxime or amp/ aminoglycoside
    • or acyclovir if herp expected
  7. empiric trmt 29-90day SBI
    • well appearing no CSF pleocytosis- ceftriaxone
    • CSF pleo or ill appearing- vanco and amp/ ceftri or cefotaxime
  8. fever in infants 3-36 months (infectious)
    • Fever can be caused by infectious and noninfectious processes
    • Vast majority of infants with fevers have an infectious process
  9. fever 3-36 months Noninfectious etiologies to consider
    • Drug fever
    • Immunization reactions
    • Malignancy (leukemia)
    • Inflammatory conditions ( Idiopathic arthritis)
  10. Fever in infants 3-36 months therapy if unimmunized
    • ceftriaxone im
    • clindamycin iv then po if PCN/ ceph allergy
  11. Worrisome S/S
    • Bulging fontanels
    • Vomiting
    • Irritability
    • Inconsolability
    • >1 febrile sz
    • Petechiae
  12. Out patient therapy for fever
    • Acetaminophen 15 mg/ kg every 4 hrs
    • Ibuprofen 10 mg/kg every 6 hours
    • Alternating between Acetaminophen and Ibuprofen can be done every three hours
    • Abx where appropriate
  13. OM causes
    • RSV
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Moraxella Catarrhalis
  14. OM peak incidence and prevalence
    • 1-2 yo, 80% have it by age 3
    • Mc cause of childhood hearing loss
  15. OM risk factors
    • Age 6-18 months
    • Parental Hx OM as child
    • Day Care Attendance
    • Lack of breastfeeding
    • Smoking
    • Pacifier use
    • Native Americans, Alaskan and Canadian Eskimos
  16. OM Clinical Manifestations
    • Hx of acute onset signs/symptoms
    • Pain
    • Precludes normal activity or sleep
    • Middle Ear Effusion(MEE)
    • Bulging of the TM
    • Limited or absent mobility of the TM
    • Air-fluid level behind the TM
    • Otorrhea
  17. Treatment OM
    • Amoxicillin 90mg/kg divided into every 12 or 8 hours
    • Pen allergic
    • Macrolide
    • Clindamycin
    • Most cases improve within 48-72 hours with
    • treatment
  18. OM Complications
    • Hearing Loss
    • Ruptured TM
    • Mastoiditis
    • Facial paralysis
    • Labyrinthitis
    • Petrositis
    • Brain Abscess
    • Meningitis
  19. Erythema InfectiosumEtiology
    • Caused by parvovirus 19 (Erythrovirus)
    • Typically seen late winter and spring April and May
  20. Erythema Infectiosum SS
    • Fever
    • Coryza
    • Headache
    • Mild gastrointestinal distress; nausea/diarrhea
    • “Slapped-cheek” occurs ~ 1 week of symptom onset
  21. Erythema Infectiosum treatment and prognosis
    • supportive Tylenol- Motrin
    • Prognosis
    • Occasionally transient aplastic crisis may occur.
  22. Varicella Prevalence
    • Prior to immunization universally communicable infection
    • winter and spring
    • Higher rates in families
    • contagious 24-48 hr before the rash and until vesicles are crusted, ~3-7 days (begins 14-16 days after exposure)
  23. Varicella Clinical Manifestations
    • Fever, usually 100-102°F but may be as high as 106°F
    • malaise, anorexia, headache
    • occasionally mild abdominal pain occurs 24-48 hours before the rash appears.
    • Varicella lesions often appear first on the scalp, face, or trunk.
  24. Treatment and prognosis
    • Typically supportive
    • Fever reduction
    • Rarely acyclovir may be recommended (20 mg/kg/dose, maximum 800 mg/dose) given as 4 doses/day for 5)
    • Prognosis
    • Most individuals fully recover
    • VZV remains dormant along nerve roots Herpes Zoster
    • Vaccinate patients
  25. Coxsackie Etiology
    • hand foot and mouth dz
    • Viral illness caused by Enteroviruses
    • Transmission primarily by respiratory droplet contact
    • feco-oral contact in developing countries
    • Usually self-limited
  26. Coxsackie Clinical Manifestations
    • 4- to 6-day incubation period, development of odynophagia, sore throat, malaise, and fever
    • Often hx of exposure
    • 1 to 2 days p symptom onset oral lesions appear
    • 75% of cases sill have concomitant skin lesions
    • Typically on the hands and feet
  27. Coxsackie Treatment and prognosis
    • Palliative therapy
    • Hydration
    • Magic Mouthwash
    • IV fluids for dehydration
    • Prognosis
    • Rare cases of central nervous system or cardiac involvement
  28. Pneumonia etiology, neonates, 3 wk-30 mo, 4 mo- 4yr, 5 yr
    • neo- group B strep, e coli, gram neg
    • 3wk-3 mo- RSV, Parainflu, influ, S .Pneumo
    • 4mo-4yr- RSV, Parainflu, influ, S .Pneumo
    • 5yr- M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae
  29. Pneumonia RF
    • M, Lower socioeconomic
    • School-age children
    • Lung/ heart Dz
    • Sickle cell disease
    • Neuromuscular disorders
    • Gastrointestinal disorders (eg, GERD, tracheoesophageal fistula)
    • Congenital and acquired immunodeficiency disorders
    • Exposure to cigarette Smoking
  30. Pneumonia Clinical Manifestations
    • Fever: Bacterial>viral pneumonia
    • Tachypnea is the most consistent clinical manifestation of pneumonia
    • Resp distress
    • It is often not possible to distinguish viral pneumonia clinically from disease caused by Mycoplasma and other bacterial pathogens.
    • Bacterial pneumonia in adults and older children typically begins suddenly with a shaking chill followed by a high fever, cough, and chest pain.
  31. Pneumonia Bacterial-outpatient therapy
    • Amoxicillin
    • Atypical organism: Macrolide (Zithromax)
    • C. pneumoniae, Mycoplasma pneumoniae
    • admit if less than 6 mo, or in distress
  32. pneumonia Bacterial-in-patient therapy
    • 3rd generation cephalosporin (ceftriaxone)
    • If evidence of staphylococcal pneumonia Vancomycin
  33. pneumonia prognosis
    • Most pt’s improve 48-96 h of treatment
    • No improvement should raise concern for:
    • Empyema
    • bacterial resistance
    • nonbacterial etiologies such as viruses and aspiration of foreign bodies or food
    • bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs
    • pre-existing diseases such as immunodeficiencies
  34. RSV Epidemiology
    • Peak age 2-6 months
    • Late fall early Spring
    • M>F (1.5-1)
    • Viral shedding 5-7 d
    • spread to the upper respiratory tract by contact with infective secretions
  35. RSV S/S
    • Bronchiolitis, cough, wheezing, and respiratory distress (retractions) Clinical findings include hyperexpansion of the lungs, (Seen on CXR)
    • Hypoxemia and hypercapnia
    • Interstitial infiltrates, often with areas of pulmonary collapse
    • The duration of acute illness is often 10 to 14 days.
  36. RSV W/U
    • Labs-Rapid RSV
    • Other labs not typically helpful
    • CXR-peri-bronchial cuffing
    • Hyperexpansion
  37. Measles Etiology
    • Caused by Morbillivirus
    • Spread though respiratory droplets
    • Infectious from 3 days before to up to 4-6 days after the onset of rash.
    • Decreased prevalence secondary to vaccine
    • ~100 cases/year in the US
  38. Vaccine MMR timing and phases
    • MMR given at 12-15 months95% effective
    • Second dose confers 99% immunity
    • incubation period- 8-12 days
    • prodromal illness-Virus shedding begins
    • exanthematous phase-antibody production begins
    • recovery
  39. Measles Clinical Manifestations
    • high fever
    • Prominent exanthem
    • Cough
    • Coryza
    • Conjunctivitis
    • Koplik spotspathognomonic sign of measles occurs 1 to 4 days prior to the onset of the rash
  40. Measles Treatment
    • Supportive
    • Antipyretics
    • Hydration
    • Ventilator support in pneumonia
  41. Measles Prognosis
    • 2/1,000 fatalities
    • Pneumonia and encephalitis were complications in most of the fatal cases
    • immunodeficiency conditions were identified in 14-16% of deaths.
  42. Mumps Etiology
    • Rubulavirus
    • winter and spring months
    • respiratory droplets
    • <300/annually
  43. Mumps Clinical Manifestations
    • Symptoms begin 16-18 d p exposure
    • Mumps virus targets the salivary glands, central nervous system, pancreas, testes
    • Effects to a lesser extent, thyroid, ovaries, heart, kidneys, liver, and joint synovia
    • fever, headache, vomiting, and achiness.
    • Parotitis may be unilateral and can be bilateral in about 70% of cases
  44. mumps Treatment Prognosis
    • Prevention-MMR
    • Reducing the pain associated with mumps
    • Hydration
    • Antipyretics
    • prog- Excellent
    • Rare deaths have occurred secondary to encephalitis
  45. Rubella (German measles or 3-day measles)Etiology
    • Rubivirus
    • Incubation-2-3 weeks
    • Viral shedding from the nasopharynx begins about 10 days after infection and may continue up to 2 wk following onset of the rash
    • The period of highest communicability is from 5 days before to 6 days after the appearance of the rash.
  46. Rubella Risk Factors
    • Mild disease not easily discernible from other viral infections
    • Rash similar to Measles
  47. Rubella trmt prognosis
    • supportive
    • vaccine
    • prog-Thrombocytopenia
    • Arthritis
    • Encephalitis
    • headache, seizures, confusion, coma, focal neurologic signs, and ataxia.
  48. Congenital Rubella Syndrome Characterized by
    • cataracts
    • congenital heart disease
    • rubella infections
    • hearing loss
    • microcephaly
  49. Roseola Etiology
    • Roseola is caused by human herpesvirus-6 (HHV-6)
    • incubation period 5 and 15 days p exposure
  50. Roseola Prevalence
    • Roseola is a benign viral illness found in infants and characterized by high fevers, followed by a rash
    • one third of all infants develop roseola before the age of 2 yr (peaks between 6-9 months)
    • 90% of children older than 2 yr of age are seropositive for the virus
    • There is no predilection for gender or time of year
  51. Roseola clinical manifest
    • Fever up to 104° F lasting 3 to 5 days
    • runny nose, irritability, fatigue
    • rash appears within 48 hr of defervescence and typically fades away within 48 hr
    • maculopapular rash that blanches when palpated
    • Anorexia
    • Seizures
    • Cervical adenopathy
  52. Roseola Treatment
    • Supportive care
    • Hydrate-PO fluids
    • Tylenol/Motrin PRN
  53. Roseola Complications
    • Febrile seizures most common complication
    • Meningitis
    • Encephalitis
    • Pneumonitis
    • Hepatitis
  54. Pharygitis Etiology
    • Viruses
    • adenoviruses, coronaviruses, enteroviruses, rhinoviruses, respiratory syncytial virus [RSV]
    • Bacteria
    • Group A β-hemolytic streptococcus
    • group C streptococcus
  55. Pharygitis Prevalence
    • Commonly occurs in close contact
    • Fall>winter> spring
    • Relatively uncommon before 2-3 yr of age
    • Peak incidence in the early school years, and declines in late adolescence and adulthood
  56. Pharyngitis clin manifest
    • rapid onset of streptococcal pharyngitis is often
    • sore throat and fever
    • absence of cough
    • Headache and gastrointestinal symptoms (abdominal pain, vomiting)
    • tonsils a yellow, blood-tinged exudate.
    • petechiae or “doughnut” lesions on the soft palate and posterior pharynx,
    • anterior cervical lymph nodes are enlarged and tender
    • RashScarlitina AKAScarlet Fever
  57. Pertussis etiology
    • Highly contagious, acute respiratory illness caused by Bordetella pertussis
    • Gram-negative coccobacillus
  58. Pertussis Transmission-virulence
    • Respiratory droplets
    • Invades local respiratory epithelium by:
    • Tracheal cytotoxins
    • Dermonecrotic toxin
    • Incubation period after exposure 7-10 days
  59. pertussis phases and symptoms
    • Catarrhal phase Lasts 1-2 weeks non specific symptoms
    • Paroxysmal phase- 2nd week- Hallmark symptomparoxysmal cough
    • Convalescent phase- Gradual reduction in frequency and severity of cough
  60. pertussis dx
    • bacterial culture- affected by abx use
    • PCR- not affected
  61. pertussis trmt
    • 80-90% of patients will improve without treatment
    • Tx early does hasten recovery especially in the Catarrhal phase
    • Tx later in the disease may not hasten recovery BUT will reduce spread
    • Azithromycin (Zithromax)
    • Clarithromycin
    • Trimethoprim-sulfamethoxazole (Bactrim)
  62. pertussis mc complication
    pneumonia- primary or secondary bacterial infx
  63. kawasaki dz S/S
    • Fever M/C symptom
    • Mucous membrane findings are seen in approximately 90 percent of cases
    • ocular changes in >75 percent
    • cervical lymphadenopathy in 25 to 70 percent
    • Extremity changes-late in dz
  64. kawasaki dz Risk Factors
    • greatest in children who live in East Asia or are of Asian ancestry
    • Typically kids < 5
    • M>F
  65. kawasaki Etiology
    • Vasculitis of Unknown origin
    • THEORY-Possible Immunologic response 
    • Affects medium-sized arteries
    • fatalities that occur within the first two weeks of fever onset and may represent an innate immune response
  66. kawasaki dz labs
    • Increased ESR
    • Increased platelets
    • +/- leukocytosis
    • normocytic, normochromic anemia
  67. kawasaki diagnosis
    • fever lasting ≥five days PLUS at least 4 of the 5:
    • Bilateral Conjunctival injection
    • Oral mucous membrane changes
    • -injected or fissured lips
    • -injected pharynx
    • -strawberry tongue
    • Peripheral extremity changes
    • palms or soles, edema of hands or feet (acute phase), and periungual desquamation (convalescent phase)
    • Polymorphous rash
    • Cervical lymphadenopathy (at least one lymph node >1.5 cm in diameter)
  68. kawasaki Tx
    IVIG within the first 10 days of illness reduces the prevalence of coronary artery aneurysms fivefold
  69. moro reflex
    dropping baby abduct limbs
  70. babinski
    toe fans out, big toe doraflex
  71. parachute reflex
    stick arms out
  72. walk reflex
    try and walk if stand up
  73. root reflex
    strok cheek turn
  74. stroke reflex
    suck
  75. pastia lines
    petechiae in antecubital crease
  76. babkin reflex
    both arms held down neck extends and turns
  77. still murmor
    innocent louder when supine 2-7 yo
  78. adrenarc
    early sexual maturation
  79. protoporphyrin
    see elevated levels in fe deficiency

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