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Study Notes Pediatrics

Study Notes Pediatrics



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Study Notes Pediatrics
Study Notes Pediatrics

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Published by: MedShare on Apr 01, 2010
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Study Notes – PediatricsJames Lamberg28Jul2010DO NOT DISTRIBUTE - 1 -
: Nelson Essentials of Pediatrics, Pediatric Secrets, First Aid for Pediatric Clerkship
--------------------------------------------------------------------------------------------------------------------------------------------Common Problems in Pediatrics
Preventative: Immunizations, Normal Growth and DevelopmentCough: URI, Asthma, Pneumonia, Bronchiolitis, Allergic RhinitisFever: Common Viral Illnesses, UTI, Occult Bacteremia, Meningitis, Febrile SeizuresSore Throat: Group A Beta-Hemolytic Streptococcal Pharyngitis, MononucleosisEar Pain: Otitis Media, Otitis ExternaAbdominal Pain: Gastroenteritis, UTI, PID, Functional Abdominal PainDermatitis: Atopic Dermatitis, Viral Exanthems, Impetigo, Monilial and Tinea Infections, ScabiesHeart Murmurs: Innocent Murmurs, Septal DefectsDevelopmental: Developmental Delay, Failure to ThriveHematology: Sickle Cell Disease, Thalassemias Nephrology: UTI, Nephrotic/Nephritic Syndromes, ProteinuriaChronic: Allergies, Asthma, Cerebral Palsy, Cystic Fibrosis, Diabetes Mellitus, Seizure Disorders
 NEJM Videos In Clinical Medicine: http://www.nejm.org/multimedia/videosinclinicalmedicine
How To Succeed – First Aid For The Pediatrics Clerkship (Stead, Stead, & Kaufman)
 Be On Time
: Most wards teams begin rounding around 8am. Give yourself at least 15 minutes per patient for pre-rounding to learn about events that occurred overnight or lab/imaging results.
 Dress In A Professional Manner 
: Regardless of what the attending wears. A short white coat should be worn over your professional dress clothes unless it is discouraged.
 Act In A Pleasant Manner 
: The medical rotation is often difficult, stressful, and tiring. Smooth out your experience by being nice to be around. Smile a lot and learn everyone’s name. Don’t be afraid to ask how your resident’sweekend was. If you do not understand or disagree with a treatment plan or diagnosis, do not “challenge.” Instead,say “I’m sorry, I don’t quite understand, could you please explain...” Show kindness and compassion toward your  patients. Never participate in callous talk about patients.
Take Responsibility
: Know everything there is to know about your patients: their history, test results, details abouttheir medical problem, and prognosis. Keep your intern or resident informed of new developments that they mightnot be aware of, and ask them for any updates you might not be aware of. Assist the team in developing a plan;speak to radiology, consultants, and family. Never give bad news to patients or family members without theassistance of your supervising resident or attending.
 Respect Patient’s Rights
1) All patients have the right to have their personal medical information kept private. This means do not discuss the patient’s information with family members without that patient’s consent, and do not discuss any patient inhallways, elevators, or cafeterias.2) All patients have the right to refuse treatment. This means they can refuse treatment by a specific individual (you,the medical student) or of a specific type (no nasogastric tube). Patients can even refuse life-saving treatment. Theonly exceptions to this rule are if the patient is deemed to not have the capacity to make decisions or understandsituations, in which case a health care proxy should be sought, or if the patient is suicidal or homicidal.3) All patients should be informed of the right to seek advanced directives on admission. Often, this is done by theadmissions staff, in a booklet. If your patient is chronically ill or has a life-threatening illness, address the subject of advanced directives with the assistance of your attending.
More Tips
: Volunteer, be a team player, be honest, and keep patient information handy.
 Present In An Organized Manner 
: “This is a [age] year old [gender] with a history of [major/pertinent history suchas asthma, prematurity, etc. or otherwise healthy] who presented on [date] with [major symptoms, such as cough,fever, and chills], and was found to have [working diagnosis]. [Tests done] showed [results]. Yesterday/ overnightthe patient [state important changes, new plan, new tests, new medications]. This morning the patient feels [state the patient’s words], and the physical exam is significant for [state major findings]. Plan is [state plan].”
On Outpatient 
: The ambulatory part of the pediatrics rotation consists of mainly two parts: focused histories and physicals for acute problems and well-child visits. Usually, you will see the patient first, to take the history and dothe physical exam. It is important to strike a balance between obtaining a thorough exam and not upsetting the childso much that the attending won’t be able to recheck any pertinent parts of it. For acute cases, present the patientdistinctly, including an appropriate differential diagnosis and plan. In this section, be sure to include possibleetiologies, such as specific bacteria, as well as a specific treatment (e.g., a particular antibiotic, dose, and course of 
Study Notes – PediatricsJames Lamberg28Jul2010DO NOT DISTRIBUTE - 2 -treatment). For presentation of well-child visits, cover all the bases, but focus on the patients’ concerns and your findings. There are specific issues to discuss depending on the age of the child. Past history and development isimportant, but so is anticipatory guidance–prevention and expectations for what is to come. The goal is to be bothefficient and thorough.
Top 100 Secrets – Pediatric Secrets (4th, Polin & Ditmar)
1) Methods to increase compliance by adolescents with medical regimens include the following: simplifying theregimen, making the patient responsible, discussing potential side effects, using praise liberally, and educating the patient.2) A pelvic examination is not required before prescribing oral contraceptives for teenagers without risk factors.Appropriate screening for sexually transmitted diseases and possible cervical dysplasia can be scheduled, butdelaying oral contraception unnecessarily increases the risk of pregnancy.3) Emergency contraception should be discussed with all sexually active adolescents; 90% of teenage pregnanciesare unintended.4) Teenagers with attention deficit hyperactivity disorder (ADHD) and conduct disorders are at high risk for substance abuse disorders. Substance abuse is often associated with comorbid psychiatric disorders.5) Calluses over the metacarpophalangeal joints of the index and/or middle fingers (Russell sign) may indicaterepetitive trauma from self-induced attempts at vomiting in patients with eating disorders.6) Appreciating that ADHD is a chronic condition (like asthma or diabetes) is useful for management strategies,follow up, and ongoing patient/parental education and involvement.7) Although colic is common and resolves spontaneously by 3 months, do not underestimate the physical and psychological impact of the condition on a family.8) Bilingual children develop speech milestones normally; two-language households should not be presumed as acause of speech delay.9) Most amblyopia is unilateral; vision testing solely with both eyes open is inadequate.10) Congenitally missing or misshapen teeth can be markers for hereditary syndromes.11) Syncope in a deaf child should lead one to suspect prolongation of the QT wave on the electrocardiogram.12) Bounding pulses in an infant with congestive heart failure should cause one to consider a large patient ductusarteriosus.13) If a bruit is heard over the anterior fontanel in a newborn with congestive heart failure, suspect a systemicarteriovenous fistula.14) The chief complaint in a child with congestive heart failure may be nonspecific abdominal pain.15) Diastolic murmurs are never innocent and deserve further cardiac evaluation.16) Patients with atypical Kawasaki disease (documented by coronary artery abnormalities despite not fulfillingclassic criteria) are usually younger (<1 year old) and most commonly lack cervical adenopathy and extremitychanges.17) Neonates with midline lumbosacral lesions (e.g., sacral pits, hypertrichosis, lipomas) should have screeningimaging of the spine performed to search for occult spinal dysraphism.18) Hemangiomas in the "beard distribution" may be associated with internal airway hemangiomas.19) Infantile acne necessitates an endocrine workup to rule out precocious puberty.20) If a child develops psoriasis for the first time or has a flare of existing disease, look for streptococcal pharyngitis.21) Look for associated autoimmune thyroiditis in children who present with a family history of thyroid disease andextensive alopecia areata or vitiligo.22) Most cardiac arrests in children are secondary to respiratory arrest. Therefore, early recognition of respiratorydistress and failure in children is crucial.23) Because children are much more elastic than adults, beware of internal injuries after trauma; these can occur without obvious skeletal injuries.24) Because children get colder faster than adults as the result of a higher ratio of body surface area to body mass, besure that hypothermia is not compounding hemodynamic instability in a pediatric trauma patient in shock.25) Hypotension and excessive fluid restriction should be avoided at all costs in the child in shock with severe headinjury because such a patient is highly sensitive to secondary brain injury from hypotension.26) The most common finding upon the examination of a child's genitalia after suspected sexual abuse is a normalexamination.
Study Notes – PediatricsJames Lamberg28Jul2010DO NOT DISTRIBUTE - 3 -27) Because the size of a normal hymenal opening in a prepubertal child can vary significantly, the quality andsmoothness of the contours of the hymenal opening, including tears and scarring, are more sensitive indicators of sexual abuse.28) Palpation for an enlarged or nodular thyroid is one of the most overlooked parts of the pediatric physicalexamination in all age groups.29) Because 20-40% of solitary thyroid nodules in adolescents are malignant, an expedited evaluation is needed if anodule is discovered.30) Unless a blood sugar level is checked, the diagnosis of new-onset diabetic ketoacidosis can be delayed becauseabdominal pain can mimic appendicitis, and hyperventilation can mimic pneumonia.31) Beware of syndrome of inappropriate antidiuretic hormone secretion and possible cerebral edema if a normal or low sodium level begins to fall with fluid replenishment during the treatment of diabetic ketoacidosis.32) Acanthosis nigricans is found in 90% of youth diagnosed with type 2 diabetes.33) Growth hormone deficiency present during the first year of life is associated with hypoglycemia; after the age of 5 years, it is associated with short stature.34) Fecal soiling is associated with severe functional constipation.35) More than 40% of infants regurgitate effortlessly more than once a day.36) Nasogastric lavage is a simple method for differentiating upper gastrointestinal bleeding from lower gastrointestinal bleeding.37) Conjugated hyperbilirubinemia in any child is abnormal and deserves further investigation.38) Potential long-term complications of pediatric inflammatory bowel disease include chronic growth failure,abscesses, fistulas, nephrolithiasis, and toxic megacolon.39) Bilious emesis in a newborn represents a sign of potential obstruction and is a true gastrointestinal emergency.40) In patients with Down syndrome and behavioral problems, do not overlook hearing loss (both sensorineural andconductive); it occurs in up to two thirds of patients with this condition, and it can be a possible contributor to thosetypes of problems.41) Fluorescence in situ hybridization (FISH) is indicated for the rapid diagnosis of trisomies 13 and 18 and multiplesyndromes in children with moderate to severe mental retardation and apparently normal chromosomes(subtelomeric FISH probes).42) Three or more minor malformations should raise concern about the presence of a major malformation.43) The diagnosis of fetal alcohol syndrome is problematic in infants because facial growth and development canmodify previously diagnostic features over a 4- to 6-year period.44) Diabetes mellitus is the most common teratogenic state; insulin-dependent diabetic mothers have infants with aneight-fold increase in structural anomalies.45) An infant with nonsyndromic sensorineural hearing loss should be tested for mutations in the connexin 26 gene.Mutations in that gene contribute to at least about 50% of autosomal recessive hearing loss and about 10-20% of all prelingual hearing loss.46) In children <12 years old, the lower limit of normal for the mean corpuscular volume (MCV) can be estimatedas 70 + (the child's age in years)/mm3. For a patient that is more than 12 years old, the lower limit for a normalMCV is 82/mm3.47) In the setting of microcytosis, an elevated red blood cell distribution width index suggests a diagnosis of irondeficiency rather than thalassemia.48) After iron supplementation for iron-deficiency anemia, the reticulocyte count should double in 1-2 weeks, andhemoglobin should increase by 1 gm/dL in 2-4 weeks. The most common reason for persistence of iron deficiencyanemia is poor compliance with supplementation.49) Children with elevated lead levels are at increased risk for iron deficiency anemia because lead competitivelyinhibits the absorption of iron.50) Chronic transfusion therapy to reduce sickle hemoglobin levels to 30-40% of the total lowers the likelihood of stroke.51) Because 30% of patients with hemophilia have no family history of the disorder, clinical suspicion is importantin the presence of excessive and frequent ecchymoses.52) Marked neutropenia (<500/mm3 absolute neutrophil count) in a previously healthy child often heralds the onsetof overwhelming sepsis.53) The determination of immunoglobulin G subclass concentrations is meaningless in children who are less than 4years old.54) Neutrophil deficiency should be considered in a newborn with a delayed separation of the umbilical cord (>3weeks).

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