paspacjourney
- Oct 16, 2022
- 30 min read

S01E08 HIGH YIELD PEDIATRIC MEDICINE

Here you will find the transcript for the HY Peds episode as well as resources used for the show cited below.

Hello and welcome to PASPAC, your audio passport from Physician Assistant Student to Certified – And beyond! With your host, Rebecca Harrell, MPA, PA-C

Today, our destination is HY Pediatric Medicine based on the EOR content Blueprint

Sit back, relax, and let’s get to it

Hey everyone, it’s Becca – as you know, we’ll be diving into Pediatrics today going in descending order of the contents covered on the Pediatric EOR blueprint and followed up with a mix pediatrics rapid review at the end.

Let’s begin with Dermatology, which makes up 15% of the EOR

DERMATOLOGY (15%)

While working at an Urgent Care, you visit a 12 year old male presenting with him mom for a new rash on his legs. History reveals the rash developed after he was playing outside near a stream in his backyard. Visualization of the rash reveals erythematous linear distributions with overlying vesicles and bullae configured in streak like patterns. The patient says they are pretty itchy and you visualize excoriations to the site. Suspecting this patient was exposed to a trifoliate plant that possesses the allergen Urushiol, what is the first line pharmacological therapy you recommend to ease his symptoms?

HIGH POTENCY STEROID like Clobetasol Propionate 0.05% Ung BID x 14 days

High potency steroids are useful for treatment of many intensely pruritic or inflamed dermatological conditions on the body, especially in patient’s like ours who have Allergic Contact Dermatitis, likely from Poison ivy.
Suspect this diagnosis in patients with history of being outdoors and visualization of various patterns matching suspected allergy. For example, someone allergic to Nickel may have an itchy vesicular rash where their pants button is and someone with Poison Ivy may tend to have a streaky appearance to the rash on either UE or LE from where the leaves brushed up against them. Typically, you will see Koebner’s Phenomenon, which is the streak-like configuration of dermatitis secondary to scratching or rubbing and spreading the allergen away from the site.
Allergic Contact Dermatitis is a self-limited condition that should resolve on its own a few weeks after the exposure is identified and removed
On the body, you can use high potency steroids for no more than 12 weeks for symptomatic treatment. Longer than this and the patient runs a risk of developing depigmentation light-discoloration and thinning of their skin that area
On the face, you need to use low potency steroids like Hydrocortisone

Your pediatric patient with a history of seizures arrives to the ER with mucosal erosions and severe conjunctivitis which developed following a period of fever and malaise. Physical exam reveals Nikolsky positive bullae on his face and thorax which cover ~8% of his body surface area. Upon taking history, you found he started a new medication for his seizures ~ 8 weeks ago. What diagnosis do you suspect?

STEVEN JOHNSON SYNDROME

SJS is a blistering dermatological condition that is typically associated with drug reactions or infection.
The most common cause of SJS is starting new medications. Notorious offenders include Carbamazepine, Lamotrigine, Sulfonamides, Allopurinol, and NSAIDs
Infections are the second most common cause of SJS, most notably Mycoplasma pneumoniae.
Suspect this in a patient with prodromal fever and malaise within 8 weeks of starting a new medication with subsequent eruption of bullae and vesicles that involve both the skin and at least 2 mucosal sites, covering < 10% BSA. SJS is more common in children, while TEN is more common in elderly patients.
Differentials should include Erythema Multiforme and Toxic Epidermal Necrolysis
Erythema Multiforme, while similar, is not considered the same as SJS. This is a Type IV Hypersensitivity that can also break out on the body and mucosa, however, is far less severe than SJS and is more commonly related to infections, rather than drugs, such as Herpes Simplex Virus.
Skin lesions in EM are described as non-pruritic targetoid with dull violet/dusky centers and associated vesicles and central bullae. Nikolsky sign will be NEGATIVE, aka pulling down next to the lesions will not separate the top skin layer as it does in SJS and TEN.
Alternatively, TEN or Toxic Epidermal Necrolysis, can be thought of as the same as SJS but covers ) 30% BSA, not < 10% like SJS.
Treatment for both SJS and TEN include discontinuing the offending medication and referral to a burn center where they will receive similar management as those with major burns, such as debridement and wound care, fluid and electrolyte management, and nutritional support. Treatment for EM includes systemic steroids, if severe enough, and any ocular involvement would warrant immediate ophthalmic referral. If EM is recurrent, daily antivirals, like Acyclovir, can be considered.

Your patient is a 4 year old unvaccinated male who presents with a rash that began at his scalp and seems to have spread down to his body. His mom states prior to this he had a mild fever for about 4 days but now fever is pretty high. Physical reveals a young boy in no acute distress who is coughing with a stuffy and runny nose and bloodshot, watery eyes. What oral mucosal finding might you have visualized had the patient come in during his febrile period?

KOPLIK SPOTS

Koplik spots, associated with Measles (Rubeola, 1st Disease) are very small, grayish macules with surrounding pink erythema on the buccal mucosa that almost appear like flecks of sand in the cheek. This usually occurs 4 days prior to the rash and may be completely gone by the time the patient presents to you.
Rubeola should be considered in young patients without history of vaccination who present with the 3 C’s (Cough, Coryza, and Conjunctivitis) with red maculopapular exanthem spreading cephalocaudally, aka from the scalp to the torso/extremities, that will become confluent and then desquamate .
You can definitively diagnose this with serologic confirmation via serum IgM antibody
Treatment is supportive, as this is due to an RNA virus – ss-RNA virus in the family paramyxoviridae and morbillivirus
Suspect history of Measles in a patient who develops Subacute Sclerosing Panencephalitis up to 8 years later.

Differentials for Rubeola include the other numbered exanthem, most importantly 2nd, 3rd, 5th, and 6th Disease. Skipping 4th’s Disease, as this is not commonly tested on, can you name the numbered exanthems in order starting from 1st Disease, which is Rubeola?

1st Disease – Rubeola (Measles)

2nd Disease – Scarlet Fever (Scarlatina)

3rd Disease – Rubella (3-Day Measles)

5th Disease – Erythema Infectiosum (“Slapped-Cheek” Fever)

6th Disease – Roseola Infantum (Exanthema Subitum)

All 5 of these numbered exanthems are important to know and high yield for many exams. I highly recommend creating a comparison chart to highlight the differences and similarities between these.

I’ll go through a few high yield comparisons first here to help you get started

Which ones of these present with HIGH fever? 1st, 2nd, 6th (Rubeola, Scarlet Fever, and Roseola)

Which ones present with LOW fever? 3rd, 5th (Rubella and Erythema Infectiosum)

Which one can be treated with antibiotics? 2nd only – Scarlet Fever is caused by Group Strep

Which is the only one that starts on neck/truck first before spreading to face/extremities? 6th (Roseola)

Which ones have immunizations? 1st, 3rd - Rubeola and Rubella

Which are associated with oral lesions? 1st (Rubeola, Koplik Spots), 3rd (Rubella, Forchheimer Spots), and 6th (Roseola, Nagayama Spots)

Which are some important complications of each?

1st (Rubeola) most commonly causes diarrhea with most common ca use of death being pneumonia. A high yield complication to remember is development of encephalitis up to 8 years later called Subacute Sclerosing Panencephalitis

2nd (Scarlet Fever) can lead to GAS complications like Rheumatic Fever/Heart Disease, Acute Glomerulonephritis, Streptococcal Toxic Shock or Reactive Arthritis, and PANDAS which is Pediatric Autoimmune Neuropsychiatric Disorders Associated with GAS.

3rd (Rubella) typically is not dangerous to adults or children that acquire it in the community but can lead to severe harm if exposed in-utero and is considered a TORCH syndrome. Congenital Rubella can lead to fetal death, premature, delivery, haring loss, developmental and growth delay, congenital heart disease, and ophthalmic defects and “Blueberry Muffin Rash” (along with another TORCH, Congenital CMV)

5th (Erythema Infectiosum) typically not dangerous but can lead to Aplastic Crisis in those with the hemolytic anemias, Sickle Cell Disease and G6PD Deficiency .

6th (Roseola) is typically benign but cause extremely high fevers which make up 1/3 cause of all febrile seizures.

Aside from our numbered exanthems, there are some other high yield pediatric exanthems that can be added to your comparison chart, such as Varicella, Molluscum Contagiousm, Kawasaki Disease, and Hand-Foot-Mouth Disease. Adding these differentials to the equation, lets do some more comparisons.

Which are considered desquamating rashes? Measles, Scarlet Fever, Rubella, and Kawasaki Disease. Of note, Erythema Multiforme, SJS, TEN, Staphylococcal Scalded Skin Syndrome, and Toxic Shock Syndrome can also cause desquamating rash. Make sure you’re reading your history closely for your unique identifiers.

Which are associated with a “Strawberry Tongue?” – 2nd (Scarlet) and Kawasaki (Mucocutaneous Lymph Node Syndrome)

Which can lead to cardiac conditions? 2nd (Scarlet) leading to Rheumatic Heart Disease, Congenital 3rd Disease (Rubella) leading to congenital heart disease like PDA, and Kawasaki leading to Coronary Artery Disease (20%)

Which can lead to vesicopapular lesions? Varicella (Chicken Pox) and Hand-Foot-Mouth Disease (Coxsackie Virus A), and sometimes Molluscum Contagiousm can appear this way, but these will be waxy and flex-colored with central umbilication. Varicella will lead to crops of grouped vesicles in various stages of healing (commonly described as “dew drop on a rose petal”) and HFMD will show vesicular ulcers in mouth and on palms and soles.

Your patient is an 8 year old unvaccinated male who presents to the urgent care with his parents due to waking up with painful swelling on one side of his face around his cheek following complaining of an earache with fever last night. Visualization of his oral mucosa reveals erythema and edema surrounding the Stenson Duct. What viral offender do you suspect causing this patients current infection?

PARAMYXOVIRUS

This patient is presenting with Mumps, which is a viral illness that typically affects the parotid gland but can really affect any gland.
Suspect this in any patient without their mumps vaccine who presents with unilateral parotid swelling and tenderness that develops within 2 days of a non-specific flu-like prodrome
Patients may also present with orchitis and even pancreatitis as these are complications seen in Mumps
Treatment is supportive as this is self-limited and therapy should focus on reducing inflammatory pain and maintaining appropriate hydration
Vaccinations for Mumps is included in the MMR series which can be given in 2 doses in children ~1 years old and again between 4-6 years old

Your patient is a 15 year old female who presents to clinic with pruritic salmon colored papules that started on the trunk, seeming to follow the skins’ cleavage lines, but now are also affecting his palms and soles. He stated prior to the “spread” of the rash, he had one single, rather large, patch of erythema that now has regressed slightly with surrounding scale at the margins. What diagnosis do you suspect?

PITYRIASIS ROSEA

This self-limiting, inflammatory rash has an unknown etiology and usually affects adolescents which may have history of recent viral illness.
Suspect this in a patient that describes an initial “herald patch” that presented before any of the other lesions
Lesion pattern is classically described as “Christmas Tree Distribution”
Because this rash affects the palms and soles, remember to rule out your must-not-miss differential by history or lab work, which is Secondary Syphilis
Treatment for Pityriasis is supportive and pruritis can be relieved with antihistamines or even topical steroids. Lesions typically fade overtime, but there may be some associated post-inflammatory hyperpigmentation

Your 5 year old patient arrives to the clinic with her mom due to intense itching on her hands that is getting worse overtime. Physical reveals small linear lesions and associated excoriations in the webbing of her fingers. Scraping of the lesion and subsequent microscopy confirms your suspected diagnosis. What is the first line treatment for this patient?

PERMETHRIN 5% CREAM

This is first line for anyone at least 2 months or older presenting with Scabies Infection.
Suspect this in patients with intense pruritus, typically worse at night, with evidence of linear burrowing and papular lesions, typically found in webbed spaces of fingers and toes. Because this is so pruritic, hemorrhagic excoriations may be seen as well.
Confirming diagnosis of Scabies is done through direct visualization of either mites, eggs, or feces under microscopy
Treat entire family and close contacts with Permethrin with repeat dose after 10 days.
Second line treatment includes PO Ivermectin. Historically, topical Lindane was used in this diagnosis, but is no longer recommended due to neurologic toxicity.
Of note, topical permethrin is also first line for pediculosis (aka lice)

Okay, we’ll get into more HY Derm later on. Next up is HEENT which makes up 15% of the EOR

HEENT (15%)

Your patient is a 4 year old female that returns to the clinic for the 3rd time for an ear infection. Her mom states she had tried to treat her at home with left over medications, but she now has unmanageable pain, fever, and otorrhea. Physical reveals her affected ear is anteverted and there is tenderness and swelling of the post-auricle area. What is first line for suspected diagnosis?

IV AMPICILLIN-SULBACTAM +/- GENTAMYCIN

This patient likely has Mastoiditis which is a complication from Acute Otitis Media infection that spreads into the mastoid air cells.
This diagnosis can be confirmed on CT which will show coalescence of mastoid air cells and possible subperiosteal abscess. Culture of the middle ear fluid should be obtained so empiric board spectrum treatment can be deescalated to agent that will tackle offending agent.
Most common organisms causing AOM is H. Flu, with others including M.Cat and S. Pneumonia.
Thus, treatment in pediatrics can include IV Ampicillin-Sulbactam with possible Gentamicin or Amikacin as this covers MRSA and the beta-lactamase producing gram negatives. If Amp-Sul is not on the answer choices, consider alternate choice of IV Cephalosporin with Vancomycin if MRSA suspected.
If there isn’t any improvement in the patient’s condition following empiric therapy, consider Myringotomy. Should patient have any intracranial complications, cholesteatoma, granulation tissue, or there is no improvement following Myringotomy, immediate mastoidectomy is warranted.

Your 17 year old female patient presents to the ER with her parents after waking up this morning with her eyes practically “glued shut” from discharge. She stated last night she had some irritation in her eyes, but now they are very red with purulent drainage. Her medical history is unremarkable aside from Contact Lens use. What treatment should she receive?

FLOROQUINOLONE GTTS.

While bacterial conjunctivitis is generally self-limited, antibiotics can be prescribed, especially in those with contact lens use due to common offending organism of pseudomonas aeruginosa that can be effectively treated with FQs.
In patients with history of sexual risk factors or neonates with bilateral copious purulence suspect N. Gonorrhea and treat accordingly as this is considered sight-threatening
The most common bacterial causes of conjunctivitis in children are the same as the most common organisms in Sinusitis and AOM – S. pneumo, H. Flu, and M.Cat

Your patient is a 12 year old male who presents to the ER due to extreme orbital swelling that is preventing him from opening his eye. History is unremarkable aside from double sickening event about a week ago which was treated with Amoxicillin which he did not finish. He reports painful and deep tenderness of the affected area with painful range of motion. When looking at him from above, you note proptosis as well. What diagnosis do you suspect?

ORBITAL CELLULITIS

This patient should be treated for Orbital Cellulitis which is a vision threatening complication of sinusitis as the pathogens migrate through the ethmoid sinus into the orbit and infiltrating the fat and muscles in the posterior orbital septum.
Because this is a complication of sinusitis typically, the most common pathogens are the similar however, this diagnosis will be more commonly associated with Staphylococcus aureus.
Treatment includes admission and delivery of IV broad spectrums covering for beta-lactamase producing gram negatives and MRSA, such as IV Vancomycin with a 3rd Gen Cephalosporin

Your 3 year old unvaccinated patient presents to ER following acute onset of fever of 102.0 F with difficulty breathing. He is sitting forward in a tripod position, hyperextending his neck, and drooling. He has stridor and is crying. What should be done next?

SECURE THE AIRWAY

This patient is at a high risk of losing his airway and patient requires endotracheal intubation first and foremost
Following securing the airway, if necessary, you can confirm you suspicions of Epiglottitis initially with Lateral Head/Neck XR showing a “thumbprint sign” and definitively with laryngoscope visualization showing an enlarged cherry-red epiglottis.
The most common cause of Epiglottitis in unvaccinated populations is H. influenza type B, but in those with vaccinations suspect Streptococcus infection
Any time there is risk of losing the airway, securing is your first step (remember your ABCs – Airway, Breathing, Circulation)
There is typically a pretty rapid response to IV Ceftriaxone or Cefotaxime, so intubation usually less than a week
Differentials to keep in mind include Laryngotracheitis, Pertussis, Peritonsillar Abscess, and Retropharyngeal Abscess, which we will get into a little more later.

For now, we’ll touch on Infectious Disease which makes up 12% of the EOR

INFECTIOUS DISEASE (12%)

Your patient is a 17 year old female who presents to the urgent care with new onset rash following empiric treatment last week for her fever, malaise, and sore throat. Physical reveals bilateral cervical lymphadenopathy and tonsillar exudate. She has a diffuse maculopapular rash and abdominal palpation reveals enlarged mass in the LUQ. How should you confirm suspected diagnosis/

HETEROPHILE ANTIBODY TEST (Mononuclear Spot Test)

EBV is the most common cause of Infectious Mononucleosis and should be suspected in teenagers that present with similar symptoms of Strep Throat, but will have any or all of the following differences
Posterior Cervical LAD
Splenic Enlargement
Maculopapular rash eruption following Amoxicillin (if originally treated for strep)
Diagnosis can be confirmed with MonoSpot and peripheral smear usually reveals atypical lymphocytes
Treatment is supportive but patients should be instructed to avoid contact sports for at least 4 weeks following infection due to high risk of splenic rupture

Your 8 month old patient arrives to the ER due to new onset distressing cough following a few weeks of low grade fever and rhinorrhea. Exam reveals an audible whoop of inspiration following an intense paroxysm of coughing. His parents state they brought him in after they saw he was coughing so hard he made himself throw up once and started to turn blue. At this time, he seems to be maintaining his own airway fine. What treatment do you recommend?

AZITHROMYCIN > TMP-SMX

This should be initiated the second you suspect a patient has Pertussis, aka Whooping Cough, which is a highly contagious respiratory illness caused by organism Bordetella Pertussis.
Suspect this in young patients, especially with history of daycare admission, who have history of a catarrhal stage consisting of coryza, cough, and fatigue x 1-2 weeks with mild fever who later go onto the Paroxysmal stage of classing “whooping cough” that may be associated with posttussive emesis. The last phase of pertussis is Convalescent Phase in which the symptom severity gradually begins to subsite.
Prevention of pertussis can be achieved with the DTap Vaccination series which consists of 5 doses at months 2, 4, 6, 15-18, and 4-6 years and then boosted with Tdap at least once between 11-18 years old. In pregnancy, patients should receive Tdap EACH PREGNANCY around 27-36 weeks to protect neonates that are too young to receive DTap vaccinations
While treatment may not decrease patients illness severity if given after 7 days onset, it will still decrease spread to others and should be initiated.
Be cautious providing macrolides to any newborns as this is a risk for Pyloric Stenosis

Your patient is a 12 year old female who developed a non-painful and slightly pruritic gradually expanding circular area of erythema with central clearing that feels slightly warm to palpation. Medical history is unremarkable, but history does reveal she went hiking with her girl scout troop a few weeks ago. Given suspected diagnosis, what treatment do you recommend?

DOXYCYCLINE > AMOXICILLIN 10-21

Doxycycline 100 mg PO BID x 10 days is the first line for patients over 8 years old. Amoxicillin should only be used as treatment for Lyme Disease in patients that are pregnant or who have allergy to Doxycycline.
If your patient presents without any signs of Lyme Disease but has evidence of engorged tick and/or > 36 hours attached, you can give 1 dose of Prophylactic Doxycycline within 72 hours of tick removal
Lyme Disease is caused by a gram-negative Spirochete, Borrelia burgdorferi, and spread by the Ixodes Deer Tick
The disease can be broken up into 3 states
- 1st Stage is Localized disease and occurs within 1-2 weeks of exposure and presents with the classic “bulls-eye” rash (aka Erythema Migrans), as we seen in our patient. There may also be constitutional symptoms like fever, chills, headache, fatigue, myalgias, arthralgias, and LAD.
- 2nd Stage is Disseminated Disease can occur days to months to following exposure with highest yield manifestations of Bilateral Bell’s Palsy and AV Nodal Block,
- 3rd Stage is considered Late Disease and represents peripheral polyneuropathy, migratory polyarthritis, or even the development of encephalopathy. Of note, in those with neurological Lyme disease, PO or IV Ceftriaxone, Cefotaxime, or PCN G for 28 days is recommended.
In those with suspected Lyme Disease, Diagnosis is made up of two-tiered testing
- Initial test is with Enzyme Immunoassay or Immunofluorescence Essay
- If needed for confirmation, second test is with IgM and/or IgG Western Blot Test
FYI in patients that have Rocky Mountain Spotted Fever, Doxycycline is first line even if under 8 years old.

Let’s move onto Pulmonology which makes up 12% of the EOR

PULMONOLOGY (12%)

While working in the ER this fall, you visit a 2 month old patient with high fever, thick nasal discharge, and decreased PO intake for ~3 days. Physical reveals auditory polyphonic wheezing and intercostal retractions. Vital signs are notable for RR 66. CXR reveals hyperinflation and peribronchial cuffing. Nasal wash for culture and antigen assay is pending. Given your suspected diagnosis, do you recommend for management?

HOSPITALIZATION

Infants with Acute Bronchiolitis, most commonly caused by RSV in the fall & winter months, should be hospitalized if any of the following are present: Toxic appearance or poor feeding, respiratory distress seen with nasal flaring, dyspnea, costal-retractions or apnea, O2 sat < 95%, RR > 70, Age < 3 months, CXR with atelectasis, or if parents are unable to care for patient properly at home
Diagnosis is with nasal washing ro RSV culture and antigen assay
Treatment for Acute Bronchiolitis is supportive, including nasal suctioning, humidified oxygen, and antipyretics to reduce the fever. The only proven therapy to improve this diagnosis is oxygen.
- In patients that are immunocompromised, consider giving Ribavirin
- Palivizumab Prophylaxis can also be started in fall for immunocompromised or premature infants
The highest risk for Apnea is in premature patients under 2 months old

You are visiting a 4 year old patient with limited past medical history due to inconsistent care givers who has been brought in by his foster family for the 3rd time this year for sinusitis. Physical reveals wheezing and cough with visualization of nasal polyps on exam. He is lower than expected weight for his age. What should be done to diagnosis this patient with suspected autosomal recessive disorder?

QUANTITAVIE SWEAT CHOLRIDE TEST

In patients with suspected Cystic Fibrosis, diagnosis can be made with chloride 60+ on sweat test in the setting of either chronic pulmonary disease, exocrine pancreatic insufficiency, or positive family history
- Second line testing that can be done to prove inadequate pancreatic exocrine function is fecal elastase
Cystic Fibrosis is a common Autosomal Recessive disorder that results from defects in sodium/chloride channels
If ever asked for most common organism causing pulmonary infections in these patients, the answer is pseudomonas aeruginosa
Suspect this diagnosis in any neonate with meconium ileus at birth or loss of vas deferens.
Given routine testing in neonates, typically patients will not wait this long for a diagnosis, however in patients with lack or resources or easily lost to follow up, consider this diagnosis if recurrent sinus or pulmonary infections are occurring. Consider this diagnosis in any child with nasal polyps on exam
Given the salt wasting, patients may present with hypochloremia metabolic alkalosis
Management is extensive, including medications to clear secretions, chest physiotherapy, anti-inflammatories, bronchodilators, replacement of pancreatic enzymes and fat soluble vitamins, and eventual lung transplant

Time for Cardiology, accounting for 10% of this EOR

CARDIOLOGY (10%)

Your patient with PMHx congenital SNHL presents to the ER following with syncope when running on the playground. EKG reveals QT of 465 ms. What is first line to blunt catecholamines in this diagnosis?

BETA BLOCKERS

This are first line for patients with Prolonged QT Syndrome, which is typically asymptomatic, but may present with palpitations, seizures, or syncopal events.
In children 1-15 years old, QT interval is considered prolonged above 460 Ms.
There are 3 main types of Long QT depending on where defect is, either LQT1, LQT2, or LQT3
Those with LQT3 typically require cardiac pacing or even ICD given increased risk of Torsades and Sudden Cardiac Death

Your young patient with unremarkable medical history arrives to her annual physical exam before starting Kindergarten and is found to have a short, systolic murmur that is more intense at the apex when she is lying down and has a musical-vibratory quality. Blood pressure and pulse pressures are normal and she is in no acute distress. What diagnosis do you suspect?

INNOCENT/ STILLS MURMUR

Murmur of childhood that is not associated with any cardiac disease and should lessen or go away overtime
Differentials to rule out include Coarctation of the Aorta and Patent Ductus Arteriosus
CoA can be ruled down by comparing upper and lower blood pressures and pulse strength
PDA can be ruled down by calculating pulse pressure (wide may suggest PDA)
If there are suspicions or patient has abnormal BP gradient or weak/wide pulse pressure, refer to cardiology

Your pediatric patient presents to his 2 month pediatric check-up and his parents express worry over still finding it very hard to feed him. They state he has difficulty feeding and tends to turn blue any time he feeds or cries. Auscultation of the heart reveals a harsh, systolic ejection murmur overlying the LUSB with a palpable thrill. What is your suspected diagnosis?

TETROLOGY OF FALLOT

This is the most common cyanotic congenital heart defect that has 4 distinct components which can be remembered by the mnemonic PROVe: Pulmonary Stenosis, Right Ventricular Hypertrophy, Overriding Aorta, and Ventricular Septal Defect
Suspect this in an infant with cyanosis when crying or feeding or in an older toddler that commonly squats (which increases their SVR to counteract “tet spells”)
The defects result a harsh systolic ejection murmur over the LUSB that has a palpable thrill
During work up, CXR will be notable for a “boot-shaped heart” which is may be described as a cardiac silhouette with upturning of the apex with decreased pulmonary markings. To definitively diagnose, order an echocardiogram, as you do for nearly all other structural cardiac conditions.
Initial treatment aims to counteracting tet spells by increasing SVR and decreasing PVR by placing patient in a knee-to-chest position and administering oxygen or even morphine if needing to calm the patient and decrease tachycardia
- Depending on severity, the next step is surgical correction which is elective unless there are recurrent episodes of severe, unremitting hypoxemia

Ok, moving to GI which makes up 10% of the EOR

GI/NUTRITION (10%)

Your 6 year old pediatric patient is brought into the clinic due to fecal incontinence and constant streaking in his underwear. His parents state he had no difficulties with toilet training, but since starting school last year he seems to be constantly “leaking” fecal matter. When they try to get him to use the restroom, he cries and refuses. Physical exam reveals a large left sided mass and abdominal XR shows evidence of excessive stool burden. What is this patients diagnosis and how would you treat?

ENCOPRESIS

Encopresis is typically seen in young school age children with history of completed toilet training and new onset fear or resistance to toilet due to fear of pain or embarrassment at school.
Because they have chronic withholding, the distension of their rectum will subsequently alter the neuromuscular response to fecal urges and there will be leakage around the impacted and hardened stools presenting as incontinence and possibly persisted odor of fecal matter.
The first line treatment includes patient and parent education and positive support to break the cycle of withholding, such as scheduling regular toilet patterns.
To reduce the stool burden, initial daily osmotic laxatives, like polyethylene glycol x 6 months, is well-tolerated and useful to reduce the painful hard stools and encourage regular stooling and neuromuscular recovery.
Should there be a large impaction noted, you may need to also give a sodium phosphate enema in addition to the laxative, but this can be very traumatizing for a young patient and so first line should be aimed at the least invasive option.
Should there be no response to initial and supportive treatment options, refer patients to GI where they can be further worked up/treated as necessary

Your patient is a neonate with trisomy 21 who has not yet passed meconium. He has bilious vomiting within hours of his first feed and he has no abdominal distension. Abdominal XR reveals abdominal distension with air collection seen in the proximal duodenum without any distal obstruction or signs of malrotation. What is the first line treatment for suspected diagnosis?

NGT DECOMPRESSION AND IVF

This patient has Duodenal Atresia which is a congenital malformation of the intestinal lumen that leads to obstruction and presence of the “double-bubble” sign on abdominal imaging.
Commonly, patients with Duodenal Atresia will be described with history of other congenital anomalies such as Trisomy 21 (Down Syndrome) or even polyhydramnios in-utero.
Bilious vomiting on the first day of life with or without abdominal distension and failure to pass meconium should heighten this on your differential.
Treatment is with NGTD and IVF with surgical repair once stabilized
Differentials include Malrotation, which typically presents in infants as bilious vomiting within 1st week of life and a concomitant acute bowel obstruction, Intussusception which typically does not appear until ~5 months old, and pyloric stenosis which typically presents within 2 weeks -2 months old with NON-bilious vomiting after eating and palpation of a small mass in the RUQ, and Hirschsprung Disease which also presents with failure to pass meconium with bilious emesis and abdominal distension but imaging will reveal a distal obstruction and typically there is a discussion of either hypertonicity on anorectal manometry, visualized transition zone on contrast imaging, and/or absent ganglion cells on suction rectal biopsy

Your 2 year old patient presents with his parents for new onset painless brick-colored stools. Suspecting the patient has the most common congenital anomaly of the GI track, what is the pathogenesis that led to this patients current diagnosis?

INCOMPLETE OBLITERATION OF THE VITELLINE DUCT

Around 7 weeks gestation, the omphalomesenteric or vitelline duct should obliterate, however, if this remains patent then it is termed Meckel Diverticulum, which is the most common congenital anomaly of the GIT
Remember this diagnosis with the Rule of 2s: Presents ~2 years old, defect is 2ft from the ileocecal valve, ~2” long, affects 2% of the population, and can possess 2 epithelial cell types (gastric and pancreas) which can lead to the currant-jelly or brick colored stools indicating rectal bleeding from ulcer of gastric tissue within the diverticulum
The most sensitive test for this is the Technetium Scan (Tech 99, aka Meckel Radionucleotide Scan)
Definitive treatment is with surgical excision of the diverticula
Complications which can arise from non-identifying or treating this condition is intussusception, volvulus, or even hernia.

The next section we will group together some 6% EOR Topics, which include Neuro-developmental and Psychiatry which together make up 12% of this EOR

NEUROLOGY/DEVELOPMENTAL (6%) & PSYCH/BEHAVIORAL MEDICINE (6%)

Your 4 month old patient is brought in for evaluation due to parents concern over sudden jerking spells which can present with both flexion or extension of head, neck, arms, and trunk lasting for a few seconds at a time, but more notably in clusters when she is waking up or falling asleep. Electroencephalogram is reveals diffuse giant waves with irregular multifocal sharp spikes and waves during these times. What diagnosis do you suspect is this patients diagnosis?

INFANTILE SPASMS

This can peak around 4-12 months old and is a type of epilepsy that can lead to clusters of jerk-like spasms with abnormal chaotic waves on EEG that confirms diagnosis
A major risk factor for developing this diagnosis is Tuberous Sclerosis and developmental regression needs to be watched out for to rule out develop West Syndrome
Treatment include administration of ACTH, steroids, and benzodiazepines to control seizures
Differentials include other infantile seizures, including febrile seizures which are the most common cause of seizures in infants and young children who are other wise healthy, but typically present with classic tonic-clonic presentations in the setting of a high fever; and Generalized Seizure Disorders such as Absence Seizures which typically manifest as “staring fits”, Atonic Seizures which manifest as “drop attacks”.
Additionally, want to rule out Meningitis or Encephalitis if a patient has neck rigidity, fever, or altered mental status that seems out of the realm of what you would expect in a postictal state
As with other seizure disorders, acute treatment for your seizure differentials include short acting benzodiazepines such as Lorazepam or even Diazepam should you need to administer treatment rectally

Your neonatal patient patient has physical findings of epicanthal folds, broad nasal bridge with hypertelorism, large tongue, single palmar crease, and a large gap between hallux and 2nd pedal digit. Auscultation of his heart reveals a harsh holosystolic murmur and ophthalmic exam reveals presence of brushfield spots. His parents had Quad Screening done in-utero which revealed increased beta-hCG and inhibin A with decreased unconjugated estriol and AFP. Additionally, patient had been found to have increased nuchal translucency on prenatal ultrasounds. Amniocentesis and Chronic Venous Sampling were both deferred during pregnancy. Given suspected diagnosis, how should you confirm your suspicions?

KARYOTYPING or FISH (FLUORESENCE IN-SITU HYBRIDIZATION)

Given this patients physical findings and abnormalities on prenatal screenings, the diagnosis to suspect is Trisomy 21, also known as Down Syndrome, which is the most common chromosomal disorder and cause of mental developmental delay
Most common associated comorbidities in patients with Trisomy 21 include ASD, duodenal atresia, and sterility in males
These patients have increased risk of ALL, Early Onset Alzheimer Disease, and Atlantoaxial Instability so risk reduction and regular follow ups are warranted
Other important chromosomal abnormalities to be familiar with include sex-chromosomal disorders such as Turner Syndrome, which is karyotyped 45, X0 and is seen in females with primary amenorrhea and hypogonadism due to gonadal dysgenesis and Klinefelter Syndrome, which is karyotyped 47, XXY and will typically present in stems with delayed puberty, gynecomastia, and infertility.

Your patient is a 15 year old female with concerns regarding severely depressed mood and anxiety that occur monthly. History reveals cyclical anhedonia, decreased appetite, sleep, and concentration with bloating and tenderness in her breasts that begins about a week before menses and improves a few days after menstruation begins. What is the first line treatment for this patients likely diagnosis?

SSRIs – continuously or 1 week prior to menses each month

This is the first line treatment for patients with Premenstrual Dysphoric Disorder, which can be diagnoses when patients have cyclical dysfunction in mood with at least 4 more additional symptoms which can include physical symptoms that improve after the onset of menses and are absent post-menses until ~1 week before next menstruation.
Other medications to consider include low-dose combination birth control, SNRIs, or even GNRH last line
Be careful with this question as sometimes you can be asked what will best treat their condition vs. symptoms. If asked about best treatment of symptoms, you need to see what their chief compliant is. If chief complaint is physical concerns like bloating or breast tenderness, consider OCPS over SSRIs. If chief compliant is mood, then first line treatment should focus on mood like SSRIs

While evaluating your 12 year old patient, his parents express concern over his behavioral issues and frequent calls home from school. History reveals for over 1 year he has been getting in fights at school, has been caught stealing, and last month was found vandalizing his school. He states he does these things for fun and doesn’t see any problem with his behaviors but does hate getting in trouble. What psychiatric disorder is he at increased risk for in adulthood?

ANTISOCIAL PERSONALITY DISORDER

This patient has conduct disorder, which is manifested by a period of time of at least 1 year with at least 1 conduct disturbance in the past 6 months which includes at least 3 of the following: Aggression or violence to people or animals, destruction of property, deceitfulness, theft, serious violation of the rules like skipping class or running away from home overnight.
In general, separate CD from Oppositional Defiant Disorder by the presence of violating the rights of others, which will not be seen in ODD.
You may see lack of remorse in patients with CD and the earlier the onset of CD, the more likely the patient is to develop ASPD once they reach 18.
Treatment and management should be focused on psychosocial interventions, such as parent-focused interviewing, CBT, and multisystemic therapy which is patient specific and typically care-giver driven in behavioral correction in individual, school, and family settings.

Alright, you’ve made it to the rapid review. Here we’ll mix in high yields from all the topics already covered and include topics left remaining, including Ortho/Rheum (5%), Endocrinology (3%), Hematology (3%), and Urology/Renal (3%). Buckle in, let’s get it

RAPID REVIEW

What is the primary cause of Respiratory Distress Syndrome of the Newborn?

Pulmonary Surfactant Deficiency, leading risk factor = prematurity

What should you administer to close contacts of a child diagnosed with bacterial meningitis?

Rifampin most common

What is first line treatment for Impetigo?

Topical Mupirocin or TMP-SMX if MRSA suspected

What is the first line treatment for specific phobia?

Exposure Therapy

Which reduction technique of nursemaid’s elbow (radial head subluxation) has higher initial success rate?

Hyperpronation – holding elbow with one hand with ipsilateral finger on radial head, use other hand to hyperpronate the patient’s distal forearm until palpating a “click”

What should you suspect in a febrile infant with lethargy, poor feeding, and seizures following spontaneous vaginal delivery from a patient with vesicular genital lesions during birth?

Neonatal Herpes Simplex Virus leading to herpes simplex meningitis and encephalitis (mcc encephalitis and high risk of morbidity and mortality)

When should APGAR Score be taken?

Minute 1 and minute 5 after birth. Again at 10 minutes if initial 2 scores are poor.

What is the most common viral cause of acute pharyngitis?

Adenovirus

What is the most common childhood behavioral disorder?

ADHD – hyperactivity, impulsivity, and/or inattention

What might an infant develop should IM Vitamin K not be given after delivery?

Hemorrhagic Disease of the Newborn

What virus causes Molluscum Contagiosum?

Poxvirus

What prophylaxis should a neonate receive if their mother is HBsAg+ at the time of delivery ?

Hepatitis B Immunoglobulin AND vaccine should be given immediately after delivery in addition to their regular immunization schedule with follow up screening between 9-12 months

How do you describe the murmur of a Patent Ductus Arteriosus?

Continuous machine-like murmur at the left subclavicular area

What parasitic disease can be diagnosed with the “Scotch Tape Test”?

Pinworm Infection (aka Enterobiasis vermicularis) which is a type of roundworm

What should you suspect in an obese adolescent male who presents with chronic progressive painful limp with and decreased passive internal/abduction ROM of the hip?

Slipped Capital Femoral Epiphysis (SCFE)

Bilateral hip XR (AP and Frog Leg) show classic “ice cream slipping of a cone” appearance and MRI offers definitive dx

What is the most common cause of bacterial meningitis in neonates?

E. Coli, GBS, and Listeria

However, MCC Meningitis overall is viral (enterovirus)

What differential of Epiglottitis presents with “hot-potato” or muffled voice?

Peritonsillar Abscess

Suspect when there is uvular deviation to the opposite site of a bulging posterior soft palate in setting of fever, drooling, muffled voice, and trismus (also known as “lock jaw”)

What asthma classification is given in those symptomatic 1-2x weekly and wake up with symptoms 1-2 times a month with FEV1/FVC 80%?

Mild Intermittent

What intoxication should you suspect in a 17 year old patient with drowsiness and miosis?

Opiate Use – Constriction of pupils and drowsiness, can lead to bradycardia, hypotension, coma, and respiratory arrest

What are the treatment options for Coarctation of the Aorta?

Early presentations – give Prostaglandin E1 to keep ductus arteriosus open

Should CHF present, give diuretics and inotropic drugs like dobutamine to improve ventricular function

Definitive treatment is repair either via balloon angioplasty with stent or surgical correction

What suspect in a young toddler with metaphyseal fractures and bruises in various stages of healing?

Child Abuse

Up to 50% abused infants younger than 18 months old who are abused can present with metaphyseal fractures (ex. bucket handle or corner fracture)

Other suspicious fractures include posterior rib fractures, scapular fracture, sternal fracture, or transverse long bone fractures

Bruises in various stages of healing, cigarette burns, glove-stocking burns, and physical findings that do not match historic mechanism of injury should all raise suspicion of child abuse

In infants, suspect abuse with retinal hemorrhages which classically indicates shaken-baby-syndrome

What is the Centor Criteria for Strep Pharyngitis?

Absence of cough

Exudates

Fever

Cervical Lymphadenopathy

If ¾ of these are present, you have met criteria to get a Rapid Streptococcal Test (Sensitive) and then Throat Culture (gold standard, if RST is negative)

When should birth weight triple?

Within 1st year of life

What degree of lateral spine curvature indicates surgical correction?

> 40 degrees, if only 20-40 degrees, then PT and Bracing is warranted (refer at 20 degrees)

What should be suspected in an at-term neonate that presents with increased WOB and progressive tachypnea within 2 hours of delivery with CXR revealing bilateral perihilar streaking and hyperinflation of lungs?

Transient Tachypnea of the Newborn

Benign and self-limited, caused by mild pulmonary edema due to delayed clearance of alveolar fluid following birth

What should be given to patients with Laryngotracheitis with tachypnea and costal retractions?

Racemic Epinephrine Nebulizer can rapidly vasoconstrict upper airway blood vessels to reduce swelling

In patients that have a risk or impending loss of airway, will want to stabilize this first if indicated

Corticosteroids IM or IV should also be given to decrease hospital stay and readmission in moderate cases while Mild Cases may only require observation and cool mist humidifier

What should be suspected in a 10 year old with progressively worsening bone pain in LLE at night with XR showing sunburst appearance of affected extremity?

Osteosarcoma

What is the first line treatment for oral candidiasis?

Topical Nystatin (2nd line PO fluconazole)

Which reflex is seen in a full term infant that results in sudden abduction of arms, extension of legs, and flexion of hips when position of head changes in relationship to body?

Moro Reflex, typically disappears around 4-5 months old and is most prominent within 1st month following term delivery

When should infantile strabismus disappear?

By 6 months old

What is the most common complication of Varicella?

Soft Tissue Infection (pruritic skin diseases have risk of secondary impetigo/MRSA due to excoriations)

At what age should you receive your annual influenza vaccine?

Beginning at 6 months old

When should introduction of solid foods begin in infants?

4 months old

No honey until after 1 years old

What is the most common benign bone tumor in peds?

Osteochondroma (usually seen in males 10-25 years old)

What numbered exanthem is caused by Parvovirus B19?

Erythema Infectiosum (5th Disease)

What should be suspected in child with short stature whose actual age is greater than estimated bone age?

Constitutional Growth Delay/ Puberty

If opposite is found, and bone age is greater than actual age, suspect precocious puberty or hyperthyroidism

If bone age equals actual age, suspect familial short stature syndrome

What is the most common location of an aspirated foreign body?

Right main bronchus

What is the commonly the first sign seen in patients with Acute Rheumatic Fever?

Arthritis, usually ~21 days following GAS infection and will respond to anti-inflammatory agents

What should you suspect in asthmatic patient with white plaques in oral mucosa that bleed when scraped?

Oral Candidiasis (Oral Thrush), suspect with pts who use inhaled corticosteroids or still breastfeed

What is a complication of using Intranasal Decongestants > 3 days?

Rhinitis Medicamentosa

What is the most common pathological murmur in childhood?

Ventricular Septal Defect

What is the most common cause of Impetigo?

Staphylococcus Aureus

What condition is associated with Wickham Striae?

Lichen Planus – white lines in planar papules

When should bacterial conjunctivitis over allergic conjunctivitis be suspected?

Bacterial conjunctivitis will be purulent and crusting “glued shut” eyes when asleep, typically bilateral on presentation but may present unilaterally.

Allergic conjunctivitis is going be bilateral, very pruritic, and typically clear tearing associated +/- cobblestoning mucosa on inner eyelid.

What is the most common endocrine disease in childhood?

Diabetes Type 1 (suspect with either 1st presentation DKA, or new onset weight loss with polydipsia, polyphagia, and polyuria +/- prolonged/recurrent candida infections)

What complication of sinusitis can present with painful and diminished ocular ROM and proptosis?

Orbital Cellulitis

What is the most common malignant posterior fossa tumor in a 8 year old child who presents with vision changes like diplopia and an unsteady gait in the setting of NV and HA?

Medulloblastoma

What are the criteria for Kawasaki Disease?

Fever for > 5 days + 4/5 of the following: Bilateral bulbar conjunctival injection, oral mucosal changes (fissures, strawberry tongue), peripheral extremity changes (ex. erythema hands/feet, periungual desquamation), polymorphic rash, and/or cervical lymphadenopathy

Remember, Kawasaki Disease is also known as Mucocutaneous Lymph Node Syndrome and is the #1 cause of acquired heart disease in pediatrics as it has high risk for coronary artery aneurysms and even myocarditis

What should you suspect in an infant male with excessive bleeding after circumcision, cephalohematoma following birth, or possibly even hemarthrosis?

Hemophilia (factor VIII deficiency > factor IX deficiency)

What should be suspected in a patient with history of strep who presents with hematuria, hypertension, and periorbital edema?

Poststreptococcal glomerulonephritis

What is the first line management of Epiglottitis?

Securing the airway

What is the diagnosis of a pediatric male with genital pain and swelling with inability to reduce proximally retracted foreskin?

Paraphimosis

What is the most common cause of Otitis Externa in an immunocompetent patient?

Pseudomonas Aeruginosa

What is first treatment for hyperkeratotic papules with underlying pinpoint hemorrhages if scraped?

Watchful waiting and reassurance for most pediatric patients as these typically resolve within 2 years. However, first line pharmacotherapy includes Salicylic Acid or Cryotherapy is first line for cutaneous warts. Avoid Cryotherapy in young children if possible because this is painful. Avoiding therapy in all children unless it is painful, persistent, affecting immunosuppressed child, or cosmetically unacceptable for child.

How is diagnosis of a Tinea infection made?

KOH Prep of skin scraping revealing hyphae

Perform KOH prep on all scaling rashes

What is the most common site of anterior epistaxis?

Kiesselbach’s Plexus

What cancer should be suspected in a young patient with trisomy 21, with new onset limp, bone pain, bleeding, lymphadenopathy, and hepatosplenomegaly with peripheral smear showing proliferation of blasts? Acute lymphoblastic leukemia

MC cancer in children

Good job everyone we are finished with our high yield pediatric rapid review.

As always you can access resources for this episode and the transcript at www.paspacpodcast.com.

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Don’t forget to follow the Instagram page @PASPAC_PASSPORT for even more questions, skills reviews, story quizzes, and healthcare updates.

I have been so behind with posting since starting my new job plus starting as a peer editor for iHuman cases, but I think I am starting to finally get a good schedule down so hopefully can start being more consistent for you all again with episodes and posts. However, this does conclude our first part of season 1 as we have finally reviewed high yields for each EOR!

Keep a look out for the second part of these season dropping soon which will go in depth with each system, starting with high yield cardiology.

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