Common Problems in Pediatrics

Fever of unknown origin (FUO) implies fever of prolonged duration (>=14 days), documented temeperature greater than 101 degrees on multiple occasions and uncertain etiology, for ex. infection, connective tissue disease, malignancy, etc.

History: Fever (Spiking? Intermittent? Describe the quality and duration), Toxicity (How severe is it?), Weight Loss, Anorexia
Exposure: Any ill contacts, residence (zoonotic infections), travel, food, drugs
Discriminative: Rashes, Pallor, Jaundice, Vasculitis, Tonsils, BCG flare, lymphadenopathy, hepatosplenomegaly, joint swelling.

Kawasaki Disease (aka mucocutaneous lymph node syndrome)
Three phases of the disease as listed here, some authors put "four":
Acute febrile phase - 1-2 weeks
1 The temperature is elevated (>104°F).
2 The child is irritable.
3 Bilateral conjunctivitis and rash are present.
4 The hands and feet develop the erythema and edema that cause the child to refuse to walk. Note that this finding may be the last to develop. Lack of extremity findings may cause consideration of incomplete Kawasaki disease.
5 The tongue and oral mucosa become red and cracked.
6 Hepatic dysfunction may develop.
7 Cardiac complications noted in the first stage include myocarditis and pericarditis.
Subacute phase - Begins when fever and other signs have abated. This phase should end by the 4th week.
1 This is characterized by persistent irritability, anorexia, and conjunctival injection.
2 Fever resolution begins this stage. However, persistent fever beyond 2-3 weeks may be an indication of recrudescent Kawasaki disease. (See Recrudescent Kawasaki disease below).
3 If fever persists, the outcome is less favorable because of a greater risk of cardiac complications.
4 Thrombocytosis develops, and the platelet count may exceed 1 million/mm3.
5 Desquamation of the fingertips and toes begins at this time.
6 Aneurysm formation may occur during this stage.
7 Children are at greatest risk of sudden death during this phase.
Convalescent phase - Approximately 4-6 weeks
1 This phase begins when all signs of illness have disappeared and continues until acute-phase reactants (ESR, CRP level) have returned to normal.
2 The most significant clinical finding that persists through this phase is the presence of coronary artery aneurysms.
(Taken from http://emedicine.medscape.com/article/804960-overview)

Lab test to do: Platelet count, ESR, echocardiogram (to look for coronary artery aneurysm. Big thing, can cause death)
Symptoms to look out for in your clinic: Fever, Rash, Conjunctival injection, Oropharyngeal changes, Peripheral extremity changes and cervical lymphadenopathy. Of course there are tons of other symptoms you may associate with this condition but these are the few things that you can pick up. One thing to note about this condition is that you need to have vigilant to be able to pick this condition up.
Treatment: IVIG and aspirin.

Inguinal Hernia
Patent processus vaginalis. Need to show patient how to reduce it. Do not attempt to massage it as it will cause adhesion and complications. Complication of this indirect inguinal hernia that you should pick up: distressed, irreducible, vomit or abdominal distention.

Hydrocele
Tend to get bigger during the evenings. Wait till 2years old for operation unless testis is big and tense. If there is any recent onset of tense testis, you need to exclude tumor.

Wheezing ==> High pitched musical sound heard during expiration and is caused by turbulence of air in the airway. Need to differentiate: broncholitis (viral, 3-6mths); bronchitis (viral, bacteria, atypical, affect older children); Pneumonia (viral, bacteria, atypical, any age group).
Wheezing = Mucosal edema + secretion (bronchospasm is not characteristic)
Recurrent Wheezing
1. Age -- > Congenital vs Non-congenital
2. Sudden wheezing -- > Foreign body
3. Pattern -- > Episodic vs Persistent
4. Assoc c cough -- > GERD, asthma, allergy
5. Assoc c feeding -- > GERD
6. Better/wose c positional changes -- > tracheomalacia, anomalies of great vessel
7. FH of wheezing -- > asthma, allergy
Fact about GER (affect 65% healthy infants, this is reflux, not a disease) whilst GERD affects 1:300 infants and associated with FTT, feeding/oral aversion, esophagitis
Types of childhood wheezing
Is divided into: 1) Transient Wheezing (typically occurs around 0-3 y/o during viral infection); 2) Non-atopic Wheezing; 3) IgE-associated wheezing/asthma

Intussusception
Re current jelly stool
3months to 1 year
Irritability and colicky pain
Laparotomy Reduction +/- resection

Newborn vomit
- Malrotation volvulus ==> green vomit (bilous vomit)
- Pyloric stenosis ==> 2-8wks (nonbilous projectile vomit)

Glue ear
http://www.ehealthmd.com/library/glueear/ge_whatis.html
Also known as otitis media with effusion, middle ear effusion, secreting otitis with effusion, serous otitis with effusion. (just put the effusion in it) Children comes with deafness. Frequently associated with Eustachian tube obstruction or dysfunction, e.g. adenoitis/nasopharyngitis; rhinosinusitis; cleft palate (the soft palate plays a role in closing or opening the Eustachian tube, therefore it makes sense when you don't have a soft palate, there is trouble for you to maintain the pressure in your middle ear)
Management:
1. Wait and see
2. Antibiotics (symptoms persist for more than 48 hrs), nasal steroid, decongestant
3. Surgery: ventilation tube (grommets) +/- adenoidectomy