Angel Solomon, MS PA‐C

Infant & Childhood Development y Gross Motor y 3 month –head control y 4 month –roll over y 6 month –sit independently y 9 month –crawl y 12 month –walk y 18 month –climbs stairs, run y 24 month –kick ball

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Infant & Childhood Development y Language y 2 month – coos y 6 month –babbles y 12 month – mama, dada y 18 month –4‐20 words y 24 month – combining words, 50% comprehensible

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Infant & Childhood Development y Language cont… y 3 year –75% comprehensible y 4 year – 100% comprehensible y Age 7 or 8 –speech, language, articulations close to adult

Infant & Childhood Development

y Social/Fine motor y 3 month –laugh y 6 month – reaches, feeds self y 9 month –indicates wants, pincer grasp y 12 month –imitates, follow 1 step commands

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Infant & Childhood Development y Social/Fine motor cont… y 18 month –scribbles, feeds self w/spoon, potty training, stacks 3‐4 blocks y 24 month –follow 2 step commands, wash/dry hands y 3 yr – dresses with supervision

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Newborn & Infant Growth y Newborns may lose up to 10% of their birth weight in the first week of life y Most regain birth weight in about 10 days y First 6 months: gain about 1oz/day y At 6 months: weigh 2x birth weight y At 12 months: weigh 3x birth weight, height 1.5x birth length

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Childhood Growth

y After 2 years of age: 2‐3 kg and 5‐7cm/year y Average 30 month child weighs 30 pounds and is 30 inches tall y Average 4 year‐old weighs 40 pounds and is 40 inches tall y Weight LOSS in a child is always suspicious

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Abnormal Growth y Failure to Thrive y Short Stature

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) FTT

y Definition: Weight that decreases to below the 3rd/5th percentile or weight loss that crosses 2 major percentiles y Causes: y Nonorganic: Environmental/Social is #1 (poverty, poor feeding technique, neglect/abuse, parental mental health)

y Organic – Affects every system, 1st 3 months MC due to infection, Metabolic Disease, Congenital Heart Disease, GERD, Milk Protein intolerance, Cystic UMDNJ PANCE/PANRE Review Course Fibrosis (becoming Rutgers July 1, 2013)

FTT‐continued y Initial Eval: y History – Identifies cause of in majority of cases (feeding patterns, vomiting, bowel habits, social/emotional/financial stability, development) y Physical –focus on signs of organic disease, evidence of abuse/neglect, dysmorphic features, skin lesions, heart murmur, abdominal masses, neuro exam y Labs –Cbc, Bun, Cre, Electrolytes, UA C&S y Treatment –R/O organic cause, Hi calorie diet, Education, Frequent monitoring, If severe require

hospitalization, social services UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

GROWTH DISTURBANCES y Distinguish between normal and abnormal conditions

y Tools for Evaluation: y 1. Growth Curves –critical factor in evaluation

y 2. Target Height –helpful to evaluate growth potential y Boys ‐ [(Mothers Ht in cm + 13) + Father’s Ht in cm] / 2 y Girls –[Mothers Ht in cm + (Father’s Ht in cm –13)] / 2

y 3. Bone Age –measure of skeletal maturation

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) SHORT STATURE y 1. Familial Short Stature y 2. Constitutional Growth Delay y 3. Chronic Conditions

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

SHORT STATURE y Normal Variants y Familial Short Stature –Normal birth size, deceleration on growth curve first 2 years of life, Normal bone age and puberty, target height is short y Constitutional Growth Delay –Normal birth size, growth pattern similar to familial short stature, Delayed bone age and puberty, “Late bloomers” Target height normal

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

SHORT STATURE

y Chronic conditions

y Endocrine –GH Deficiency, Hypothyroidism, Cushing syndrome/disease y Nutritional y Systemic Disease –GI, Renal, Cardiac, Pulmonary, Immunology y Genetic Syndromes –Turner, Prader‐Willi, Down

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) HEENT y URI y Amblyopia y Acute Otitis Media y ENT Foreign Bodies y Chronic Otitis Media y Otitis Externa y Croup

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

VIRAL URI y Common in any age group; especially infants and toddlers y Lasts 7‐10 days y MCC: Rhinovirus y Symptoms: y Runny nose, nasal congestion, coryza, sneezing, mild conjunctivitis, sore throat, hoarseness, cough. Fever often presents for first 2‐3days y Tx: Cough and cold medications. No antibiotics!!!

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

OTITIS MEDIA y Acute Otitis Media y Suppurative infection of the middle ear cavity y Most prevalent in children between 6 and 24 mo y Bacterial y Streptococcus Pneumoniae (most common) y Haemophilus influenza y Moraxella Catarrhalis y Viral y Respiratory Syncytial Virus y Rhinovirus y Influenza virus

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Otitis Media

y Risk Factors y Day Care Attendance y Formula Fed Infants (feeding position) y Second hand cigarette smoke

y Presentation & Diagnosis y Often follows an upper respiratory tract infection(URI) by 1‐7 days y Usually presents with fever, poor feeding, pain and/or irritability, vomiting, ear pulling y TM : bulging, red, landmarks not visualized, immobile (Pneumatic Otoscopy with evaluation of movement of TM)

y Antibiotics DOC: Amoxicillin 80‐90 mg/kg/d (erythromycin if allergic) y If tx failure after 48 hours: amoxicillin/clavulanate, cefuroxime, cefdinir, ceftriaxone UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Chronic Otitis Media y Definition – recurring or persistent infection or inflammation for several months y Risk Factors ‐ multiple ear infections, allergies, trauma, swelling of the adenoids y Sx – hearing loss, otorrhea, pressure, ear ache y PE: infxn, air‐fluid levels. discharge, perforation y Tx: Abx, Surgery (Myringotomy/Repair/Adenoids) y Complications: Mastoiditis, Deafness

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

OTITIS EXTERNA y Inflammation of the skin in the outer ear canal y Commonly caused by water trapped in the canal from swimming in lakes or pools y Pathogens: y Staphylococcus aureus y Pseudomonas aeruginosa y Symptoms: y Pain, purulent discharge, pain elicited with traction on pinna or tragus y Treatment: y Topical Antibiotic/Corticosteroid drops y (Acetic Acid/Polymyxin B/Neomycin/Quinolone)

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Viral Croup

Viral Croup – Laryngotracheobronchitis

Most common cause of stridor in children

y Peak ages : 6 months to 3 years. Fall/Winter • Sx: Barking cough, URI symptoms, hoarseness, fever, inspiratory stridor y Pathogen: parainfluenza virus common y Diagnosis: H & P, season helpful (Fall/Winter) <50% “steeple sign on ant neck X‐ray y Treatment: Hydration, Humidity! Steroids if severe

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

AMBLYOPIA

y Definition: decreases or loss of vision in one or both eyes in the absence of ocular or CNS pathology y Initiated by any condition that results in abnormal/unequal visual input between the “critical period” of birth to 8‐9 years of age

y Dx: Visual Acuity, RF ie.. Strabismus, congenital cataracts, FHx y Tx: Patching, essential within the critical period; otherwise loss may be permanent

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

UMDNJ PANCE/PANRE Review Course Courtesy of Dean John Bonsall, MD, FACS (becoming Rutgers July 1, 2013) ENT FOREIGN BODIES y Commonly seen: Buttons, beads, marbles, nuts, toy parts, Bugs too y Ear: Ear pain, drainage, hearing loss y Nose: Unilateral purulent rhinitis, persistent sinusitis, blocked nasal passage on exam y Removal: Do not blindly probe! If visible, forceps, curette, Foley (inflated past foreign body), etc Restraint is essential to prevent further injury

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Which of the following is the most common presenting symptom of epiglottitis in a child? 1. Early morning sputum production 2. Muffled phonation 3. Barking cough 4. Rhinorrhea

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Which of the following is the most common presenting symptom of epiglottitis in a child? 1. Early morning sputum production 2. Muffled phonation 3. Barking cough 4. Rhinorrhea

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) When treating clinical croup, you could reasonably include all of the following except: 1. IV steroids 2. Intubation 3. Racemic epinephrine 4. Oxygen and cool mist 5. IV Ceftriaxone

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

When treating clinical croup, you could reasonably include all of the following except: 1. IV steroids 2. Intubation 3. Racemic epinephrine 4. Oxygen and cool mist 5. IV Ceftriaxone

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

A 15 month old male presents with a 2 day history of upper respiratory infection type symptoms followed by a barky cough and low grade fever. Which of the following is the most appropriate management of this patient? 1. Albuterol 2. Racemic L‐ epinephrine 3. Intubation for ventilatory support 4. IV Antibiotics 5. Dexamethasone IV, IM or PO

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) A 15 month old male presents with a 2 day history of upper respiratory infection type symptoms followed by a barky cough and low grade fever. Which of the following is the most appropriate management of this patient? 1. Albuterol 2. Racemic L‐ epinephrine 3. Intubation for ventilatory support 4. IV Antibiotics 5. Dexamethasone IV, IM or PO

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

An 18 month old male is brought to the emergency department because he has had a fever and cough for the past 3 days. PE shows an ill appearing but well hydrated child with a bright red tympanic membrane and green discharge from the nose. Temp is 103F. CXR is negative. Which of the following is the most likely dx?

1. Serous otitis media 2. Acute otitis media 3. Chronic otitis media 4. External otitis media 5. Cholesteatoma

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

An 18 month old male is brought to the emergency department because he has had a fever and cough for the past 3 days. PE shows an ill appearing but well hydrated child with a bright red tympanic membrane and green discharge from the nose. Temp is 103F. CXR is negative. Which of the following is the most likely dx?

1. Serous otitis media 2. Acute otitis media 3. Chronic otitis media 4. External otitis media 5. Cholesteatoma

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Lungs y Bronchiolitis y Hyaline Membrane Disease y Pneumonia y Cystic Fibrosis y Viral y Foreign bodies y Bacterial y Atypical y Pertussis

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

BRONCHIOLITIS

y The most common lower respiratory illness in infants and young children less than 2 years old. y Pathogen: Respiratory Syncytial Virus(RSV) in 50‐90% of cases y Symptoms: Cough, mild fever, tachypnea, and wheezing. Thick nasal congestion y Diagnosis: RSV antigen nasal wash. CXR ‐ Hyperinflation WBC ‐ Increases lymphocytes y Treatment: Controversial y Nebulized albuterol commonly used y Oral steroids if sx severe y Ribavirin has been used in hospitalized cases y Synagis now used to prevent RSV in preemies

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

PNEUMONIA ‐ VIRAL y Common in all age groups; follows URI y Etiology: y MCC of pneumonia in children. RSV (MC), parainfluenza, & influenza viruses y Symptoms: y URI precedes onset of cough y Wheezing, grunting, nasal flaring common y Labs: y WBC may be low, normal, or slightly elevated. A high WBC makes viral etiology unlikely y Imaging: y CXR may show perihilar streaking, increased interstitial markings, peribronchial cuffing y Treatment: y It is rarely possible to reliably differentiate viral from bacterial pneumonia based upon history, exam, labs or radiographs y Therefore it is common for appropriate concomitant antibiotic coverage to be used for viral pneumonia in children UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) PNEUMONIA ‐ BACTERIAL y Inflammation of the lung classified according to the infecting organism and site y Occurs in all age groups, but more commonly in children < 2 years old y Common pathogens: y S. pneumoniae, Group A strep y Group B strep (neonates) y Symptoms: y URI precedes abrupt onset of fever, chills, SOB, anorexia, cough, dyspnea y N/V, abdominal/chest/shoulder pain typical, malaise

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Pneumonia ‐ Bacterial y Signs: y tachypnea:reliable sign of pneumonia in kids! y Cough, grunting, nasal flaring, y Exam usually shows decreased breath sounds, rales, dullness to percussion,but can be normal y Wheezing unusual in bacterial pneumonia unless pt has baseline reactive airway disease y Labs: y WBC >15,000 or greater y Blood cultures positive in 10‐15% of cases y Imaging: y Lobar consolidation, patchy infiltrates common y May see effusions y Atelectasis vs infiltrate ‐ often hard to tell y Treatment: UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) y Neonates: IV ampicillin/gentamycin y Others: penicillin. Amoxicillin, 2nd or 3rd generation cephalosporin

PNEUMONIA ‐ ATYPICAL y Chlamydia pneumonia y Occurs between 2 weeks to 6 months of age. Peak incidence (>90%) by 8 weeks y Most common cause of pneumonia in children under 6 months of age (25‐45% of cases) y Pathogen: C. trachomatis (maternal STD) y URI prodrome; nearly 100% afebrile y Staccato cough, tachypnea, rales, conjunctivitis y Dx: Nasal wash, eosinophilia common y Tx: Erythromycin. Hospitalization for those with paroxysmal cough, apnea, resp distress

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Pneumonia ‐ Atypical y Mycoplasma pneumonia: y Common over the age of 5 years, esp teens y Pathogen: Mycoplasma pneumonia y Long incubation: 2‐3 weeks y Symptoms: Gradual onset, Dry cough, progressing to productive. Fever,HA, malaise, y Signs: Rales, bullous myringitis y CXR: Middle and lower lobe infiltrates y Tx: Macrolides usually shorten course and may lessen severity of symptoms

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

PERTUSSIS “Whooping Cough”

y Infants/toddlers; un‐/partially immunized y Pathogen: Bordetella pertussis Spread by teens/adults who are no longer immune y Sx: 3 stages y Cattarhal: URI (1‐2 weeks) y Paroxysmal: Staccato cough and ‘whoop’ on inspiration(1‐2 weeks) y Convalescent: Dry cough (1‐2 weeks) y Dx: Hx, characteristic paroxysmal cough y Tx: Erythromycin

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Hyaline Membrane Disease y Cause: Deficiency of surfactant y S&S: increased RR, cyanosis, expiratory grunting y Dx: CXR shows hypoexpansion, B/L atelectasis y Tx: Oxygen, early intubation, ventilation Surfactant replacement

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) CYSTIC FIBROSIS y Most common severe inherited disease in the Caucasian population ‐ 1:2500 y Resp symptoms: chronic cough or sinusitis, recurrent pneumonia, nasal polyps, clubbing y GI symptoms: meconium ileus (20%), pancreatic insufficiency (85%), failure to thrive y Dx: Sweat chloride is the “gold standard” >60meq/L is abnormal. Genetic testing y Tx: ATB, pancreatic enzymes, bronchodilators, postural drainage. Mean survival age is increasing!

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

RESPIRATORY FOREIGN BODIES

y Throat: Stridor, choking, cyanosis. (Can also occur if foreign body is in esophagus) y Ball‐valve effect may cause hyperinflation y Heimlich if suspected upper airway FB and respiratory distress y Rigid bronchoscopy if in lower airway.

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Angel Solomon, MS PA‐C Angel Solomon, MS PA‐C

Cardiology y Acquired Heart Disease y Functional murmurs y Rheumatic Fever y Still’s Murmur y Venous Hum y Congenital Heart Disease y Acyanotic Lesions y Cyanotic Lesions

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

RHEUMATIC FEVER y Inflammatory disease triggered by Group A strep and can cause permanent damage to heart muscle and valves y Affects ages 5‐15 years y Jones criteria: Major ‐ carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules Minor ‐ fever, arthralgia, elevated ESR and/or C‐reactive protein,, prolonged PR interval on ECG y Dx: 2 major criteria OR 1 major and 2 minor y Tx: Bed rest, salicylates, steroids for severe carditis, chlorpromazine or Haloperidol for chorea y Prevention: Recurrences ‐ Benzathine penicillin q month

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) FUNCTIONAL MURMURS

y Still’s murmur y Most common innocent murmur of childhood y Usually age 2 years to adolescence y Loudest apex to LSB. Musical or vibratory, high pitched, I‐III early systolic y diminishes with sitting/standing/Valsalva y Venous Hum y Very common after age 3 years y Produced by turbulence in subclavian and jugular veins y Continuous, musical, I‐II at upper R, LS, & lower neck y Disappears if supine or jugular vein compression

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Cardiology Acyanotic lesions y Atrial Septal Defect (ASD) y Ventricular Septal Defect (VSD) y Most common form of congenital heart disease y Occurs in about 2 per 1000 live births y Loud, holosystolic murmur along LSB y Atrioventricular Septal Defect (AVSD) y Patent DuctusArteriosus(PDA) y Coarctation of the Aorta y BP in upper extremity 20mmHg or greater than lower extremity

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Atrial Septal Defect y Communication between right and left atria y children asymptomatic y S2 widely split and fixed y Tx: surgical repair

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Ventricular Septal Defect y Most common congenital heart disease y Communication between left and right ventricles y Small VSD ‐ asymptomatic y Large VSD ‐ present at 4‐6 weeks in congestive heart failure y loud, harsh, holosystolic murmur along the lower left sternal border y Tx: control CHF, surgery if unresponsive to meds

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Patent Ductus Arteriosus y Presence in fetal life allows blood from the pulmonary artery to flow to the aorta, bypassing the nonaerated fetal lungs y usually closes spontaneously by 3‐5 days of life y 2x more common in females y Associated with maternal rubella y Machinery murmur that is continuous and maximal at 2nd intercostal space y Tx: Medical management ie Indomethacin in preemies, may require surgical correction

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Coarctation of the Aorta y Narrowing of the aortic lumen y More common in males y Sx: CHF, HTN y Dx: 1. pulses greater in upper extremities y 2. BP of upper extremity is > than lower extremity by 20 mm Hg y 3. blowing systolic murmur in left axilla y X‐ray: notching of the ribs in older kids y Tx: Surgical correction

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Cyanotic Lesions

y Tetralogy of Fallot y VSD y Pulmonary stenosis y Overriding Aorta y RVH y Tricuspid Atresia y Transposition of the Great Vessels y Total Anomalouus Pulmonary Venous Return y Truncus Arteriosus

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Tetralogy of Fallot y Most common type of cyanotic heart lesion y 4 components: VSD, pulmonary stenosis, overriding aorta, right ventricular hypertrophy y sudden cyanosis, dyspnea on exertion ‐ hypoxemic spells aka “tet spells” y rough, systolic ejection murmur 3rd intercostal space y X‐ray: Boot shaped heart y Tx: Medical then surgical by 18 months

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

UMDNJ PANCE/PANRE Review Course Courtesy of Wikipedia (becoming Rutgers July 1, 2013) A 2 year old is brought to the ED by his mother w/ sudden onset of choking, gagging, coughing and wheezing. Vital signs are: Temp: 37C(98.6F) Pulse: 120/min, Resp: 28/min The physical exam reveals decreased breath sounds over the right lower lobe w/ inspiratory rhonchi and localized exp wheezing. CXR reveals nl inspiratory views, but exp views show localized hyperinflation, with mediastinal shift to the left. Which of the following is the most likely diagnosis?

1. Asthma 2. Epiglottitis 3. Foreign body aspiration 4. Pulmonary embolism 5. Viral pneumnia

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

A 2 year old is brought to the ED by his mother w/ sudden onset of choking, gagging, coughing and wheezing. Vital signs are: Temp: 37C(98.6F) Pulse: 120/min, Resp: 28/min The physical exam reveals decreased breath sounds over the right lower lobe w/ inspiratory rhonchi and localized exp wheezing. CXR reveals nl inspiratory views, but exp views show localized hyperinflation, with mediastinal shift to the left. Which of the following is the most likely diagnosis?

1. Asthma 2. Epiglottitis 3. Foreign body aspiration 4. Pulmonary embolism 5. Viral pneumnia

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

A 6 month old comes to your office during the winter looking mildly ill with a fever of 100.7 and a RR of 72. He has wheezing throughout his chest and scattered rales and rhonchi. Your working dx is:

1. Heart failure 2. Bronchiolitis 3. Croup 4. Epiglottitis 5. Pneumonia

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) A 6 month old comes to your office during the winter looking mildly ill with a fever of 100.7 and a RR of 72. He has wheezing throughout his chest and scattered rales and rhonchi. Your working dx is:

1. Heart failure 2. Bronchiolitis 3. Croup 4. Epiglottitis 5. Pneumonia

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

An 18 month old documented as less than tenth percentile on your growth chart is having trouble breathing. He has a history of intermittent dyspnea and a chronic cough since birth. Post delivery, the patient did not defecate for quite some time. Which of the following diagnostic tests will be most useful in this child’s evaluation?

1. Rectal biopsy 2. Chest X‐ray 3. Urine glucose assessment 4. Urine protein assessment 5. Sweat test

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

An 18 month old documented as less than tenth percentile on your growth chart is having trouble breathing. He has a history of intermittent dyspnea and a chronic cough since birth. Post delivery, the patient did not defecate for quite some time. Which of the following diagnostic tests will be most useful in this child’s evaluation?

1. Rectal biopsy 2. Chest X‐ray 3. Urine glucose assessment 4. Urine protein assessment 5. Sweat test

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Which of the following congenital heart defects is associated with cyanosis? 1. Patent ductus arteriosus 2. Atrial septal defect 3. Ventricular septal defect 4. Coarctation of the aorta 5. Tetralogy of Fallot

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Which of the following congenital heart defects is associated with cyanosis? 1. Patent ductus arteriosus 2. Atrial septal defect 3. Ventricular septal defect 4. Coarctation of the aorta 5. Tetralogy of Fallot

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Gastrointestinal/Nutrition y Pyloric Stenosis y Intussusception y PKU y GI foreign bodies

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) PYLORIC STENOSIS

y Hypertrophy of muscular layers of pylorus leading to obstruction, y Begins between ages 2‐4 weeks. Rare at birth or over the age of 6 months y Much more common in males y Classic presentation “Projectile, non‐bilious vomiting and palpable pyloric mass or “olive”. Well, hungry child y Dx: Physical exam, ultrasound.

y Tx: Surgery UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

INTUSSUSCEPTION y Invagination of part of the bowel into an adjacent part of the bowel y Most cases idiopathic; males>females y Most common from 6‐12 months of age y Sx: Paroxysmal abdominal pain is main symptom, followed by vomiting and diarrhea y “Currant‐jelly” stool in 50% of cases y Exam: Sausage‐shaped mass y Tx: Reduction (Barium enema) and/or open surgery

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

PKU y Cause: Dec activity of phenylalanine hydroxylase (enzyme that converts phenylalanine to tyrosine) y S&S: severe mental retardation, hyperactivity, seizures, light complexion, urine w/mouse‐like odor y Dx: Increased phenylalanine, Decreased tyrosine y Tx: Limit dietary phenylalanine

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) GI FOREIGN BODIES y Coins, toys, and batteries are most common y Upper esophagus ‐ remove to lower risk of aspiration (Foley catheters often used) y Lower esophagus ‐ remove if > 24 hours y Stomach ‐ < 3‐5 cm usually pass GI tract y If object is sharp or caustic (open safety pin, camera batteries) ‐ endoscopy. y If toxic (medication tablets) ‐ lavage

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

A 12 year old accidentally swallowed a broken tab from an aluminum soft drink more than 6 hours ago. She can swallow liquids but solids cause discomfort. On X‐ray, a flat metallic object is located at the level of the aortic arch. Which of the following is the most appropriate course of action: 1. Admission for surgical extraction 2. Removal of tab by endoscopy 3. Extract with Fogarty catheter 4. Gastrogafin swallow to r/o esophageal injury 5. Observation of the patient’s stool for passage of tab

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

A 12 year old accidentally swallowed a broken tab from an aluminum soft drink more than 6 hours ago. She can swallow liquids but solids cause discomfort. On X‐ray, a flat metallic object is located at the level of the aortic arch. Which of the following is the most appropriate course of action: 1. Admission for surgical extraction 2. Removal of tab by endoscopy 3. Extract with Fogarty catheter 4. Gastrogafin swallow to r/o esophageal injury 5. Observation of the patient’s stool for passage of tab

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Which of the following findings is most suggestive of a dx of pyloric stenosis in an infant?

1. Epigastric mass 2. Failure to thrive 3. Projectile vomiting 4. Abdominal distention

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Which of the following findings is most suggestive of a dx of pyloric stenosis in an infant?

1. Epigastric mass 2. Failure to thrive 3. Projectile vomiting 4. Abdominal distention

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Orthopedics y Classification of fractures y Congenital Hip Dysplasia y SCFE y Osgood‐Schlatter y Nursemaid’s Elbow

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Salter‐Harris Classification y Type I ‐ Epiphyseal separation through the physis y Type II ‐ Fracture through a portion of the physis but exiting across the metaphysis y Type III ‐ Fracture through the physis but exiting across the epiphysis into the joint y Type IV ‐ Fracture through metaphysis, physis, and epiphysis y Crush injury to the physis

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

SA

LTR Reproduced with permission of author, Dr Frank Gaillard CONGENITAL HIP DYSPLASIA (Developmental Dislocation of the Hip)

y Increased risk in first‐born females, breech birth, or family history of DDH y Dx: Screening exam essential at each visit y Ortolani (Out) test ‐ Abduct/external rotation Palpable click as dislocation reduced y Barlow test: Adduct/Internal rotation Palpable click as hip dislocates y Ultrasound under 3 months. X‐rays if older y Tx: Harness. Surgery y Complications: (untreated) Limp, pain, degenerative disease of UMDNJ PANCE/PANRE Review Course Above image courtesy of wikipedia hip (becoming Rutgers July 1, 2013)

SCFE: Slipped Capital Femoral Epiphysis

y Femoral head “slips” ‐ exposing the anterior and superior aspects of the femoral neck y Males (14‐16 yrs) > Females (11‐13 yrs) y Associated with obesity, increased height, genital underdevelopment, pituitary tumors y Sx: Acute or chronic hip or knee pain y X‐ray pearl: Ice cream falling off the cone

y Tx: Surgery UMDNJ PANCE/PANRE Review Course Above image courtesy of www.expertconsult.com (becoming Rutgers July 1, 2013)

OSGOOD‐SCHLATTER SYNDROME y Fibrocartilage microfracture of the patellar ligament y Most common in adolescent males y Activity related pain lasts 12‐24 hrs y Tenderness, thickening at tibial tubercle y X‐rays: Prominent, irregular. Fx? y Tx: Rest, ice, compression, NSAIDS

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) NURSEMAID’S ELBOW Subluxation of the Radial Head

y Occurs after forearm or wrist is jerked with longitudinal/pronational forces (“airplane”) y Common presentation: Child holds arm in y pronated and flexed position and resists extension y Dx: History, exam. Radiographs are normal y Tx: Reduction by supinating/extending arm. Splint if recurrent. Prevention

UMDNJ PANCE/PANRE Review Course Above image courtesy of wikepedia (becoming Rutgers July 1, 2013)

Skin y Measles y Mumps y Rubella y Varicella y Roseola y Erythema infectiosum y Hand‐foot‐mouth disease y Kawasaki syndrome y Review Immunization schedule

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Measles: Rubeola

y Morbillivirus in the Paramyxovirus family y Rare at any age y Incubation: 8‐12 days for sx, 14 days for rash y Prodrome: fever (101+), cough, Koplik spots, conjunctivitis y Rash: Neck & Abdomen first ‐ maculopapular y Tx: Primarily supportive

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Courtesy of Centers for Disease Control and Prevention

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

“Mumps: “Parotitis” y Paramyxovirus y Incubation 12‐25 days y Late winter & spring y Pain & swelling in front of and below ear y Often testicular pain within 1 week y Complete recovery with supportive care in 1‐2 weeks is the rule Image above courtesy of Centers for Disease Control and Prevention

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Rubella: “German measles y Rubella virus is a togavirus; Rubivirus y Rare at any age y Congenital rubella is deadly, especially in the first trimester, TRIAD: deafness, cataracts, cardiac defects y Description: Blueberry muffin baby y Acquired: Erythematous rash progressing from head to toes y PREVENTION!

Courtesy of www.expertconsult.com UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Varicella: “Chicken Pox”

y Varicella‐zoster virus y Usually 5 to 9 yrs old y Late winter/early spring y Incubation: 10‐21 days y Vesicular, erythematous rash on torso, then face and extremities y Description: “Dew drops on a rose petal” y Tx is supportive

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

y Courtesy of Centers for Disease Control and Prevention UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) y Courtesy of Centers for Disease Control and Prevention UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Roseola: “Roseola infantum” y HHV‐6 y Ages 3 months ‐ 4 years y Incubation 5‐15 days y Maculopapular rash y High fever (102‐105) for 3‐5 days y Fever starts resolving, THEN rash appears y Tx is supportive

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Erythema infectiosum: “Fifth Disease” or “Slapped Cheek Syndrome y Parvovirus y School aged children y Incubation 4‐14 days y Red facial rash and lacy, pink macular rash on torso & extremities y Pregnant woman at risk: hydrops fetalis y Tx is supportive

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Courtesy of George A Datto MD UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Hand‐Foot‐and‐Mouth Disease y Coxsackie A16 virus (most common) y Under 5 years y Incubation 3 ‐ 7 days y Late summer & fall y Painful oral ulcers, low grade fever, gray‐red vesicles on hands and feet y Tx is supportive y DDx: Herpangina/Gingivostomatitis

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) y Courtesy of Dr. William Sears, www.askdrsears.com UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

y Courtesy of Dr. William Sears, www.askdrsears.com UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

y Courtesy of Dr. William Sears, www.askdrsears.com UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Hand‐Foot‐and‐Mouth Disease y Coxsackie A16 virus (most common) y Under 5 years y Incubation 3 ‐ 7 days y Late summer & fall y Painful oral ulcers, low grade fever, gray‐red vesicles on hands and feet y Tx is supportive y DDx: Herpangina/Gingivostomatitis

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Kawasaki Syndrome/Disease “Mucocutaneous Lymph Node Syndrome y Etiology unknown ‐ infectious agent likely y Under 5 years old y Fever > 5 days AND four of the following: conjunctivitis, rash, mucosal changes, edema of hands/feet, cervical adenopathy > 1.5 cm y Complications: anuerysms y Tx: IVIG, Aspirin

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Recommended Childhood Immunization Schedule, United States y Rotavirus y Hepatitis A y Varicella y Pertussis y Meningococcal y Human papilloma virus

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) Six days ago, a 2‐year‐old boy had a temperature of 40.0°C (104.0°F). No specific cause was found. His fever has persisted and he now has injected conjunctivae, strawberry tongue, dry fissured lips, erythema and desquamation of his hands and feet, and bilateral cervical adenopathy. Which of the following is the most likely complication of this condition? 1. Chorea 2. Congestive heart failure 3. Coronary artery aneurysm 4. Mesenteric arteritis 5. Valvular heart disease

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

Six days ago, a 2‐year‐old boy had a temperature of 40.0°C (104.0°F). No specific cause was found. His fever has persisted and he now has injected conjunctivae, strawberry tongue, dry fissured lips, erythema and desquamation of his hands and feet, and bilateral cervical adenopathy. Which of the following is the most likely complication of this condition? 1. Chorea 2. Congestive heart failure 3. Coronary artery aneurysm 4. Mesenteric arteritis 5. Valvular heart disease

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

An 18‐month‐old boy is brought to the emergency department because he has had fever and cough for the past three days. While in the waiting room, he has a generalized tonic‐clonic seizure that lasts five minutes. He has no history of a seizure disorder. Physical examination shows a postictal child with a bright red tympanic membrane and green discharge from the nose. Temperature is 40.6°C (105.0°F). Which of the following is the most appropriate initial diagnostic study?

1. CT scan 2. Electroencephalography 3. Lumbar puncture 4. MRI scan 5. Myelography

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013) An 18‐month‐old boy is brought to the emergency department because he has had fever and cough for the past three days. While in the waiting room, he has a generalized tonic‐clonic seizure that lasts five minutes. He has no history of a seizure disorder. Physical examination shows a postictal child with a bright red tympanic membrane and green discharge from the nose. Temperature is 40.6°C (105.0°F). Which of the following is the most appropriate initial diagnostic study?

1. CT scan 2. Electroencephalography 3. Lumbar puncture 4. MRI scan 5. Myelography

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

A previously healthy 15‐month‐old boy becomes anxious and begins crying and drooling copiously. A few minutes earlier he had been calmly playing with his toys. Temperature is 36.7°C (98.1°F), pulse rate is 84/min, and respirations are 18/min. On physical examination, the posterior pharynx is mildly injected but otherwise clear. The lungs are clear to auscultation and percussion. Findings on chest x‐ray study are normal. Within an hour he is calmer, but he continues to drool heavily. Which of the following is the most appropriate next step?

1. Administration of syrup of ipecac 2. Barium swallow x‐ray study 3. Chest physical therapy 4. Esophagogastroduodenoscopy 5. Insertion of a nasogastric tube

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)

A previously healthy 15‐month‐old boy becomes anxious and begins crying and drooling copiously. A few minutes earlier he had been calmly playing with his toys. Temperature is 36.7°C (98.1°F), pulse rate is 84/min, and respirations are 18/min. On physical examination, the posterior pharynx is mildly injected but otherwise clear. The lungs are clear to auscultation and percussion. Findings on chest x‐ray study are normal. Within an hour he is calmer, but he continues to drool heavily. Which of the following is the most appropriate next step?

1. Administration of syrup of ipecac 2. Barium swallow x‐ray study 3. Chest physical therapy 4. Esophagogastroduodenoscopy 5. Insertion of a nasogastric tube

UMDNJ PANCE/PANRE Review Course (becoming Rutgers July 1, 2013)