NR 602 MIDTERM PEDIATRIC QUESTIONS AND ANSWERS| GRADED A
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NR 602
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NR 602
Growth and development – There are a lot of potential questions covering from birth to age 17
1. Chalazions: chronic inflammatory lesion that develops from meibomian tear gland obstruction.
Causes: sebaceous cell, basal cell, or Meibomian gland cancer.
Signs and symptoms: eyelid swelling and e...
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NR 602 MIDTERM PEDIATRIC QUESTIONS AND
ANSWERS| GRADED A
1. Growth and development – There are a lot of potential questions covering from birth to age 17
1. Chalazions: chronic inflammatory lesion that develops from meibomian tear gland obstruction.
Causes: sebaceous cell, basal cell, or Meibomian gland cancer.
Signs and symptoms: eyelid swelling and erythema evolving into painless, rubbery nodule at at eyelid
margin.
Treatment: warm moist compress. Resolves without treatment in several weeks. Not an infection.
Referral to ophthalmology if does not resolve or if visual fields affected.
2. Blepharitis: Inflammation of the eyelid margin. Can be acute or chronic.
Causes: Inflammation at the base of the eyelash by staph aureus, which alters meibomian eye secretion.
Contact dermatitis, eczema, psoriasis, contact lens, or smoke exposure.
Signs and symptoms: Redness, itching, irritation, gritty feeling, pink eyes, tearing, crusting or matting of
eyelashes in the morning, scaling of eyelids, blurred vision that can be blinked away, and light sensitivity.
Treatment: Nonpharmacological consists of warm moist compresses 1 to 2 X D fallowed by lid washing
with baby shampoo. Artificial tears.
Mild to moderate: Pharmacological includes erythromycin ointment (Ilotycin) 7-10 day. Bacitracin HS for
1-2 weeks. Azithromycin (Azasite) 1gtt bid X2d then qd for 5 days.
Moderate to severe: Doxycycline 100mg bid for 2 to 4 weeks or Azithromycin 500mg qd X 3d
Referral: severe eye redness and pain, light sensitivity, impaired vision, or poor response to treatment.
3. Otitis media: Inflammation or infection (bacterial or viral) of the middle ear with purulent
effusion.
Causes: strep pneumoniae, Hemophilus influenzae, Moraxella catarrhalis for bacterial. For viral
adenovirus, RSV, or influenza. Environmental exposure to sick children (i.e, daycare). Pasive exposure to
smoke or sleeping with a bottle.
Signs and symptoms:
Mild: Mild otalgia and fever < 102 F in the past 24 hours. Preverbal child may pull at ear or hair near ear
to signify pain.
Severe: moderate to severe otalgia or fever > 102 in the past 24 hours. May cry unconsolably or have
otorrhea if TM perforated.
TM abnormal in color (red or hemorrhagic) with moderate to severe bulging, impaired mobility, and
possible perforation. Fever, sinus congestion, rhinorrhea, hearing loss or decreased.
Diagnostic testing: pneumatic otoscopy for mobility.
,Treatment:
Conservative if child > 2 years of age, has mild symptoms, no otorrhea, TM intact, fever <102, patient
does not appear ill and has been healthy prior to illness.
Acetaminophen 10-15 mg/kg q4 hours or ibuprofen 10mg/kg q6hor topical analgesic drops
(antipyrine/benzocaine (auralgan) if TM intact. If no improvement in 48-72 hours start antibiotics.
First line treatment if no recurrent AOM and no recent antibiotics (within the last 30 days), and no
purulent conjunctivitis amoxicillin 90mg/kg/day divide by 2 for BID. 5-7 days for > 2 years old and 10
days if <2 years old.
For recurrent AOM, recent antibiotic use, or purulent conjunctivitis give 10 days of Amoxicillin?
Clavulanate 90mg/kg/day divided by 2.
Alternative to PCN Cefdinir 14mg/kg/day divide 2 or ceftriaxone 50mg /kg IM qd for 1-3 days
Allergy to PNC and cephalosporins
Azithromycin 10mg/kgon day one and 5mg/kg on days 2-5
Fallow up: 48-72 hours if not improving (treatment failure switch antibiotics and continue for 10 days i.e
Cefdinir). See patient 8-12 weeks after treatment to reassess TM and hearing.
Referral: ENT if unsolved and/or < 2 months of age and noted decreased hearing.
4. Bacterial Conjunctivitis: Inflammation or irritation of the conjunctiva that can be infectious or
non-infectious.
Causes: Bacteria like strep pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. Viral caused
by adenovirus, coxsackie, herpes simplex, varicella, and molluscum. Allergic IgE mast cell
hypersensitivity, cosmetics, or environmental.
Signs and symptoms: Bacterial shows purulent exudate and eyelids stuck shut in the morning. Viral with
injected conjunctiva, profuse tearing, mucous discharge, burning, sandy, gritty feeling, URI, enlarged or
tender preauricular node (initially unilateral and then bilateral (second eye infected withing 24-48
hours). Allergic diffuse injection, conjunctival edema, severe itching, tearing, sneezing, and rhinitis.
Chlamydial and gonococcal profuse exudate with genitourinary symptoms (symptom onset 2-4 days after
birth. Chemical Conjunctival erythema, discharge, symptom 30 minutes after prophylactic antibiotic
drop but resolves within 48 hours.
Nonpharm: Warm compress for infectious and cool for allergic or chemical. Good hand hygiene change
pillow case daily for bacterial or viral, discard eye makeup. Go back to school 24 hours after treatment
for infectious.
Pharm: Bacterial erythromycin ointment better for young children. Trimethoprim-polymyxin or ofloxacin.
Referral: in 4 days if not better to ophthalmology.
5. Otitis Externa: Inflammation of the EAC or auricle with redness, pain, discharge.
,Causes: increased moisture (disrupts normal flora) due to swimming in fresh or chlorinated water, high
environmental temp, chronic use of ear plug, hearing aids, removal of packed cerumen with trauma to
the canal.
Treatment: Provider removal of debris with suction or curette. Do not flush unless intact TM visualized.
Mild infection: Vosol or Vosol HC 4gtt q8h (no exposure to waterpain relief with acetaminophen 10-
15mg/kg TID or Ibuprofen 10mg/kg tid.
Follow up: 7 days
Moderate: increased pain, partial occlusion, pain with movement of pina, decreased hearing and itching.
Topical antibiotic/steroid for 7days Ofloxacin 10gtt qd, cipro/dexamethasone > 6 months age: 4gtt bid.
Cipro/hydrocortisone > 1 year 3gtt q12. Neomycin/ polymyxin/hydrocortisone >2 years 3gtt 3-4 times
daily for 10 days
FU: 2 to 5 days
Severe: intense pain with complete canal occlusion, fever, lymphadenopathy, outer ear redness, and
pain with pinna movement. Topical antibiotic/steroids, ear wick placement, and oral antibiotic for 7 days
FU: 24 to 48 hours, if infection spreading to surrounding ear skin, or not improving (urgent referral to ED)
Prevention: if involved in water sports use earplugs, shake water from ears, or use blow dryer on lowest
setting 12 inches from ears. After exposure mix rubbing alcohol and vinegar 1:1 ratio and instill a few
drops in ear. Clean hearing aids every night. No cleaning of ears with anything smaller than elbows.
6. Hand-Foot-Mouth Syndrome: Caused by enterovirus or coxsackievirus A16. Most contagious for
the first 7 days but can remain contagious for several weeks after symptoms resolve. Transmitted by
direct contact with blisters, droplet, and fecal content. Adults can be infected too.
Signs and symptoms: Abrupt onset of maculopapular vesicular lesion on palms, between fingers, and on
the soles of the feet, buttocks, legs, orals mucosa, and arms. Primary symptoms are poor appetite and
oral lesions. Fever, malaise, joint aches, and cervical adenopathy.
Treatment: self-limiting 5-7 days. Antipyretics increase fluids (cold). Oral OTC mouth wash or lozenges
(Cepacol). Benadryl liquid for pain. Carafate 1tbs 4 times a day swish and spit out to coat oral mucosa or
combination of Benadryl+xylocaine+Maalox.
7. Strep Pharyngitis
Signs and symptoms: Abrupt onset of headache and sore throat. Tonsillar exudate, tender anterior
cervical lymphadenopathy, sand paper rash (scarlatina) on face that is blanchable, abdominal pain, and
fever.
Test: Culture done in all children < 16 years old. Rapid strep test, CBC, and monospot test.
Treatment: Amoxicillin 50mg/kg/d divided by 2 for 10 days. Cephalexin 1-15 years 25-50mg/kg/d divided
by 2 for 10 days for >15 500mg bid for 10 days. Cefdinir >6 months 7mg/kg/d divided by 2, >12 300mg
bid for 5 to 10 days.
, Follow up: 48 if no improvement and switch to clindamycin or clarithromycin.
Instruction: discard toothbrush and buy 2. Use one for 48 hours then discard. Return to school after
antibiotic therapy for 24 hours and or when fever resolves.
Referral: if tonsils chronically enlarged or >6 cases a year ENT
8. Congenital Heart Defects in Children
Atrial Septal defect: An atrial septal defect (ASD) is a defect or hole in the atrial septum. Of the four
types of ASD, the most common involves the mid-septum in the area of the foramen ovale and is called
an ostium secundum-type defect. The child is often completely asymptomatic and may fatigue easily or
have exertional dyspnea, be somewhat thin, and have a history of frequent upper respiratory tract
infections or pneumonia. Symptoms may become more common in late adolescence or early adulthood.
Diagnostic Studies.
• Chest radiography may reveal cardiac enlargement, especially of the right atrium and right ventricle.
The main pulmonary artery may be dilated and pulmonary vascular markings increased.
• The ECG shows right axis deviation with right atrial enlargement. Lead V1 usually shows a right bundle
branch block with an rSR′ pattern. P wave may be tall 772showing right atrial enlargement. The PR
interval may be prolonged. However, the ECG can be normal in small left-to-right defects. The ECG
should be assessed for AV prolongation.
• The echocardiogram identifies the specific location of the defect in the atrial septum and will show
right-sided chamber enlargement.
Management
• Small defects found in infancy may close spontaneously.
• Larger defects require intervention, usually after the child is 1 year old and before school entry or
when the defect is identified in an older child. Most ASDs can now be closed in the cardiac
catheterization lab with a closure device. If the defect is large or unfavorable to device closure, cardiac
surgery is indicated.
SBE prophylaxis (see Table 31-6) precautions are necessary only in the first 6 months after cardiac
surgery or device closure (81 mg of aspirin daily for 6 months may be prescribed after device closure).
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