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  1. Pediatric Board ReviewPart Dos Mark Heller, MD Department of Emergency Medicine Mount Sinai School of Medicine

  2. Question 1 Which of the following statements regarding ingested foreign bodies is correct? • All children with suspected foreign body ingestion should undergo x-ray. • Ipecac can be used safely to dislodge a button battery in the esophagus. • Meat tenderizer can be used safely to dissolve an impacted meat bolus. • Most common site of esophageal foreign body entrapment in pediatric patients is the thoracic inlet. • Objects longer than 5cm and wider than 2cm should be removed before they pass through the stomach.

  3. Q 1 Answer Which of the following statements regarding ingested foreign bodies is correct? • All children with suspected foreign body ingestion should undergo x-ray. • Ipecac can be used safely to dislodge a button battery in the esophagus. • Meat tenderizer can be used safely to dissolve an impacted meat bolus. • Most common site of esophageal foreign body entrapment in pediatric patients is the thoracic inlet. • Objects longer than 5cm and wider than 2cm should be removed before they pass through the stomach. PEER VII Q20

  4. Swallowed Foreign Bodies

  5. Swallowed Foreign Bodies • Most pass spontaneously • Exceptions are objects longer than 5cm and wider than 2cm • Rarely pass the pylorus • Lodging in the esophagus • Children – Cricopharyngeal narrowing at level C6 (Upper Esophagus) • Adults – Lower Esophagus

  6. Swallowed Foreign Bodies (continued) • Need to be removed • Extremely pointed edges • Safety pins • Razor blades • Button Batteries • 15-35% will cause intestinal perforation • Need for X-ray • Highly debated topic • No difference in 5-day morbidity rates between x-ray and no x-ray

  7. Question 2 Which of the following organisms is most likely to cause a rash with the characteristic “slapped-cheek” appearance? a. Coxsackievirus A16 b. Group A beta-hemolytic streptococci c. Human herpesvirus C d. Parvovirus B19 e. Varicella-zoster virus

  8. Q 2 Answer Which of the following organisms is most likely to cause a rash with the characteristic “slapped-cheek” appearance? a. Coxsackievirus A16 b. Group A beta-hemolytic streptococci c. Human herpesvirus C d. Parvovirus B19 e. Varicella-zoster virus PEER VII Q309

  9. Parvovirus B19 • Erythema Infectiosum • Fifth Disease • Slapped Cheek • Viral Illness • Begins with Fever, Cold, HA • Symptoms Resolve • Slapped Cheek Rash Appears • Spreads to Trunk/Arms/Legs • Treatment is symptomatic

  10. Coxsackievirus A16 • Hand-Foot-and-Mouth Disease • Mouth Sores • Blisters on Hand • Fever • Sore Throat • Abdominal Pain

  11. Varicella-Zoster Virus • Multiple states of rash on same body part • Low-grade fever, malaise, and headache • Treatment is symptomatic • Varicella-zoster immune globulin and acyclovir for immunocompromised children

  12. Question 3 A mother brings her 14 month old son into the ED. For the past 4 to 5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct? • Affects girls more than boys • Is associated with cystic fibrosis and malnutrition • Requires excision of the lesion in the emergency department • Requires proctasigmoidoscopy • Requires referral for surgical correction

  13. Q 3 Answer A mother brings her 14 month old son into the ED. For the past 4 to 5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct? • Affects girls more than boys • Is associated with cystic fibrosis and malnutrition • Requires excision of the lesion in the emergency department • Requires proctasigmoidoscopy • Requires referral for surgical correction PEER VII Q334

  14. Rectal Prolapse • Affects very young and very old • Loose connection of mucosa to submucosa • Laxity of anal sphincter • Mucus or Blood-stained mucus in diaper • Protruding mass after bowel movement • Associated with cystic fibrosis • Reducible in ED with sedation as needed

  15. Question 4 For previously healthy children with community-acquired pneumonia, which of the following statement is correct? a. Age is the most important factor in selecting empiric antibiotic therapy b. Concurrent presence of watery diarrhea reliably identifies a viral etiology c. Localized chest pain is the most commonly associated with viral pneumonia d. Viral and bacterial pneumonias can reliably be differentiated in infants e. Wheezing in preschool-aged children is pathognomonic for viral pneumonia

  16. Q 4 Answer For previously healthy children with community-acquired pneumonia, which of the following statement is correct? a. Age is the most important factor in selecting empiric antibiotic therapy b. Concurrent presence of watery diarrhea reliably identifies a viral etiology c. Localized chest pain is the most commonly associated with viral pneumonia d. Viral and bacterial pneumonias can reliably be differentiated in infants e. Wheezing in preschool-aged children is pathognomonic for viral pneumonia PEER VII Q343

  17. Pneumonia in Children • Etiologic agents have seasonal variations • Parainfluenze Virus = Fall • RSV & Bacteria = Winter • Influenza = Spring • Clinical Features • Variable and Dependent on Age • Neonates and Young Infants • Can present w/ Sepsis Syndrome • Fever, apnea, tachypnea, poor feeding, V/D, lethargy, shock • Older Children • Fever, abnormal lung exam, cough, pleuritic chest pain

  18. Pneumonia in Children • Abbreviated Reference: • Neonates (<28 days) • Group B Strep, E.Coli, Klebsiella • Ampicillin and Cefotaxime • 1-24 months • RSV, Parainfluenza, Strep • Erythromycin, Cefuroxime, Ampicillin • 2-5 years • Influenza A and B, Strep • Amoxicillin • 6-18 years • Mycoplasma pneumoniae, S. Pneumoniae • Azithromycin

  19. Name That Saturday Morning Cartoon Character

  20. Name That Saturday Morning Cartoon Character Astro

  21. Name That Saturday Morning Cartoon Character

  22. Name That Saturday Morning Cartoon Character Betty

  23. Name That Saturday Morning Cartoon Character

  24. Name That Saturday Morning Cartoon Character Brainy Smurf

  25. Question 5 For a previously healthy toddler with mild croup, the administration of oral dexamethasone: • Is indicated only for moderate-to-sever croup, because mild croup is self-limited. • Is indicated only if the parents are unable to provide cool mist at home • Is precluded by an unacceptably high rate of uncontrollable vomiting after administration • Leads to mild hyperactivity that interferes with normal sleep patterns • Leads to quicker resolution of symptoms when compared with observation

  26. Q 5 Answer For a previously healthy toddler with mild croup, the administration of oral dexamethasone: • Is indicated only for moderate-to-sever croup, because mild croup is self-limited. • Is indicated only if the parents are unable to provide cool mist at home • Is precluded by an unacceptably high rate of uncontrollable vomiting after administration • Leads to mild hyperactivity that interferes with normal sleep patterns • Leads to quicker resolution of symptoms when compared with observation PEER VII Q347

  27. Croup • Inflammation of the Upper Airway • Epidemiology • Parainfluenza, RSV, Influenza • Clinical Features • 6 months to 3 years old • Late Fall to Early Winter • Bark-Like Cough • Biphasic Stridor • Treatment • Humidified Air • Dexamethasone in Mild to Moderate Croup • Nebulized Epinephrine (racemic epi) for moderate to severe • Intubate if necessary

  28. Question 6 For a child with stridor, which of the following best differentiates croup from bacterial tracheitis? a. Drooling and fever b. Normal chest x-ray c. Productive cough d. Rhinorrhea prodrome e. Stridor at rest

  29. Q 6 Answer For a child with stridor, which of the following best differentiates croup from bacterial tracheitis? a. Drooling and fever b. Normal chest x-ray c. Productive cough d. Rhinorrhea prodrome e. Stridor at rest PEER VII Q368

  30. Bacterial Tracheitis • Clinical Features • More severe form of croup • Bacterial superinfection • 3 months to 13 years old • S. aureus, S. pneumoniae • More respiratory distress than croup • Appear septic • Inspiratory and expiratory stridor • Thick sputum production • Raspy hoarse voice • Diagnosis • Radiograph of lateral neck and chest • Subglottic narrowing of the trachea • Treatment • Similar to epiglottitis • 85% require intubation • Vanc and Ceftriaxone

  31. Question 7 A 9 month old boy presents with hypotonia and constipation. His mother says he has recently started eating “table food.” Which of the following is the most likely diagnosis? a. Botulism b. Ciguatera c. Listeriosis d. Scombroid poisoning e. Typhoid

  32. Q 7 Answer A 9 month old boy presents with hypotonia and constipation. His mother says he has recently started eating “table food.” Which of the following is the most likely diagnosis? • Botulism • Ciguatera • Listeriosis • Scombroid poisoning • Typhoid PEER VII Q349

  33. Botulism • Toxin Produced by Clostridium botulinum • Blocks acetylcholine release at synapse causing flaccid paralysis • Onset 1 to 4 days post intake • Symptoms • Constipation • Difficulty sucking • Difficulty swallowing • Hypotonia • Care is symptomatic • Antitoxin should be given

  34. Question 8 Which of the following statements regarding intussusception is correct? • If the stool is negative for occult blood, the diagnosis is excluded. • Most patients show profound dehydration at the time of diagnosis • Mucus-laden, bloody, “currant jelly” stools are seen in most cases • Postreduction recurrence is best predicted by patient age and sex • Ultrasonography is an accepted diagnostic test

  35. Q 8 Answer Which of the following statements regarding intussusception is correct? • If the stool is negative for occult blood, the diagnosis is excluded. • Most patients show profound dehydration at the time of diagnosis • Mucus-laden, bloody, “currant jelly” stools are seen in most cases • Postreduction recurrence is best predicted by patient age and sex • Ultrasonography is an accepted diagnostic test PEER VII Q354

  36. Intussusception • Telescoping of one portion of the intestine into another • Most commonly occurs between the ileum and colon • Most prevalent 3 months to 6 years old • Presentation • Sudden abdominal pain • Pain-free intervals • Sausage-shaped mass on R • Diagnosis • US used for diagnosis • Treatment • Barium or Air enema diagnostic and therapeutic • Possible Surgical Correction

  37. Question 9 For young infants who are vomiting, which of the following is most likely to differentiate acute malrotation with midgut volvulus from pyloric stenosis? • Abdominal examination • Color of the vomitus • History of constipation • Presence of high fever • Resting tachycardia

  38. Q 9 Answer For young infants who are vomiting, which of the following is most likely to differentiate acute malrotation with midgut volvulus from pyloric stenosis? a. Abdominal examination b. Color of the vomitus c. History of constipation d. Presence of high fever e. Resting tachycardia PEER VII Q357

  39. Pyloric Stenosis • Clinical Presentation • Nonbilious Projectile Vomiting • Just after feeding • Seen in 2nd or 3rd week • Diagnosis • Palpation of pyloric mass in LUQ • US

  40. Malrotation • Clinical Presentation • Bilious Vomiting • Abdominal Distention • Streaks of Blood in Stool • Most present within first month of life • Diagnose • Abdominal Radiograph

  41. Name That Saturday Morning Cartoon Character

  42. Name That Saturday Morning Cartoon Character Skeletor

  43. Name That Saturday Morning Cartoon Character

  44. Name That Saturday Morning Cartoon Character Patrick Star (SpongeBob’s Friend)

  45. Name That Saturday Morning Cartoon Character

  46. Name That Saturday Morning Cartoon Character Snorks

  47. Question 10 Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children? • Anal fissures • Infectious diarrhea • Juvenile polyps • Milk-protein allergy • Vitamin K deficiency

  48. Q 10 Answer Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children? • Anal fissures • Infectious diarrhea • Juvenile polyps • Milk-protein allergy • Vitamin K deficiency PEER VII Q358

  49. Infectious Diarrhea • Etiology • Campylobacter • E. coli • Salmonella • Shigella • Most common cause of bloody diarrhea in school-aged children • Treatment • Treat for Dehydration • No role for antiemetics / antidiarrhea medications • No antibiotics

  50. Question 11 A 14 year old girl is brought to the emergency department because she has difficulty walking. She has been noted to have some weakness in her legs over the past 36 hours. There is no history of trauma, and she is afebrile. On examination she has normal mental status and normal strength and sensation in her arms. In her lower extremities, she ahs flaccid paralysis, absent reflexes, and no sensation. Which of the following should be done next in the ED? a. Administer an intravenous cephalosporin b. Immediately strap her down to long board c. Initiate fluid resuscitation with 2 L normal saline d. Order MRI of the spine e. Perform lumbar puncture and administer intravenous acyclovir