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Karen Estrella-Ramadan 07/03/12. Question 1 A family comes to your office for consultation regarding a 3-week trip to India they are planning to take.

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Presentation on theme: "Karen Estrella-Ramadan 07/03/12. Question 1 A family comes to your office for consultation regarding a 3-week trip to India they are planning to take."— Presentation transcript:

1 Karen Estrella-Ramadan 07/03/12

2 Question 1 A family comes to your office for consultation regarding a 3-week trip to India they are planning to take in 3 months. The children, a 9-year-old boy and a 7-month-old girl, are well, and their immunizations are up to date. Of the following, the MOST appropriate prophylaxis to provide in preparation for travel is: A. chloroquine for both children B. hepatitis A vaccination for both children C. measles vaccination for the girl D. polio vaccination for the boy E. typhoid vaccine for both children

3 C Measles: common in many parts of the world, including India. Measles vaccine is recommended for 6- to 11-month-old children, and the 7-month-old girl in the vignette should be given a dose of measles vaccine. She still will require two doses of measles-containing vaccine after 1 year of age because the immune response may be suboptimal at her young age. If the 9-year- old boy is up to date on immunizations, he requires no additional measles vaccination.

4 Chloroquine : NO, because South and Southeast Asia, sub- Saharan Africa, and tropical areas of South America are resistant to it. In these areas use atovaquone/proguanil and mefloquine. Doxycycline can be used in children older than 8 years of age. Travelers' Health – CDC Hepatitis A: is a concern, but NOT approved in kids <1y/o. Iunder this age may use: Immunoglobulin IM. The boy must get vaccine 2-4 wks before departure if hadnt got it, and then sec dose in 6-12months. Polio : NO, both are UTD in vaccines Typhoid: may be indicated for a trip to Indica longer than 2 wks, but neither of the two licensed vaccines is indicated in children younger than 2 years of age

5 Question 2 You are called by a nurse who has sustained a needle stick injury while drawing blood from a patient's central line. The patient is a 14-year-old male who recently was diagnosed with acute myelocytic leukemia. He has received several blood product transfusions for anemia and thrombocytopenia. You obtain human immunodeficiency virus and hepatitis C serologies. Of the following, the additional serologic test that MUST be obtained for the nurse is for: A. Cytomegalovirus B. hepatitis A C. hepatitis B D. measles E. tetanus

6 C Requires a serologic test for hepatitis B. Hepatitis B virus (HBV) is a DNA hepadnavirus that is comprised of an outer lipoprotein envelope containing hepatitis B surface antigen (HBsAg) and an inner nucleocapsid consisting of hepatitis B core antigen. ONLY antibody to HBsAg (anti-Hbs) provides protection from HBV infection Transmitted through: blood or body fluids (wound exudates, semen, cervical secretions, and saliva) Blood and serum highest concentrations of virus; saliva lowest. Serology is the most common diagnostic test used to detect and diagnose hepatitis B. In addition, hybridization assays and gene amplification techniques (eg, polymerase chain reaction) are available to detect and quantitate HBV DNA.


8 Cytomegalovirus, hepatitis A, and measles are NOT transmitted parenterally. Tetanus is acquired through contamination of wounds with soil or excrement that contain the tetanus organism. Needlestick injury is not a usual pathway for acquiring tetanus.

9 Question 3 A 15-year-old girl presents to the emergency department with right upper quadrant pain for 2 days that is severe enough to keep her out of school. Her appetite is decreased and she has nausea but no vomiting or diarrhea. She has mild discomfort with urination but no vaginal discharge. The only medication she is taking is combined oral contraceptive pills. Her last menstrual period was heavier that usual. Laboratory tests reveal: WBC: 7.4x10 3 /mcL (7.4x10 9 /L) with N: 64% L: 26% Total bilirubin, 0.4 mg/dL (6.9 mcmol/L) ALT: 14 units/L AST: 16 units/L Urine has 7 WBC. Abdominal US: reveals a normal liver, spleen, gallbladder, and kidneys. Of the following, the MOST likely diagnosis is 1. Cholecystitis 2. Fitz-Hugh-Curtis syndrome 3. hepatitis A infection 4. infectious mononucleosis 5. pyelonephritis

10 2 ALL adolescents should be asked annually about: sexual behaviors, unintended pregnancy and sexually transmitted infections (STIs), including HIV. Document screening and LMP Fitz-Hugh-Curtis syndrome or perihepatitis presents as RUQ pain that results from inflammation of the liver capsule from ascending pelvic infection. Although typically associated with salpingitis, it can exist without other signs of pelvic inflammatory disease and may mimic other abdominal emergencies.

11 Lab r/o hepatitis, including that caused by mononucleosis, and biliary tract obstruction. The absence of fever and the location of pain for this girl make pyelonephritis unlikely. Pyuria raises the possibility of urethritis, which commonly occurs with Neisseria gonorrhoeae and Chlamydia trachomatis infections. C trachomatis can cause inflammation of the genital tract without the classic symptoms and signs of pelvic inflammatory disease. Often, heavier menstrual flow may be the only symptom.

12 Question 4 A 15-year-old boy comes to the emergency department because of cramping abdominal pain, diarrhea, and body aches. Physical examination reveals no icterus or organomegaly, although he has increased bowel sounds and mild diffuse abdominal tenderness. His genitalia are at Sexual Maturity Rating 4. Among the results of laboratory tests obtained are: Total bilirubin, 0.6 mg/dL (10.3 mcmol/L) ALT: 18 units/L AST: 22 units/L Alkaline phosphatase: 360 IU/L Of the following, the MOST likely explanation for the results of these laboratory tests is: A. bone malignancy B. infectious hepatitis C. inflammatory bowel disease D. physiologic growth spurt E. viral gastroenteritis

13 D An increased serum alkaline phosphatase value on a LFT panel in an adolescent, often is the result of rapid bone growth during the pubertal growth spurt. Therefore, it is important to correlate the value with the Sexual Maturity Rating (SMR) rather than with chronologic age. The highest mean SAP concentrations in girls occur at SMR 2 and in boys at SMR 3, coinciding in each instance with peak height velocity and presumed maximum osteoblastic activity. (high as 500 UI/L) Osteoblasts, by creating a local environment of alkalinity via alkaline phosphatase, help build bone. With increasing SMR or age, the SAP values in both sexes decrease markedly. The normal range for children and adolescents varies with age, sex, sexual maturity, and reference laboratory. The isoenzyme test can reveal whether an elevation of SAP is from bone or liver, but this test is not widely available.


15 Pathologic causes of increased SAP include: Liver or biliary disease Pregnancy drugs (eg, phenytoin) skeletal disease endocrine disorders such as hyperPTH. Normal concentrations of liver enzymes suggest a nonhepatic cause of SAP elevation and rule out infectious hepatitis and inflammatory bowel disease with hepatic involvement. Bone pathology (eg, osteosarcoma) presents with higher SAP values than reported for this boy along with other symptoms (eg, limb pain) and signs (eg, swelling). Elevated SAP concentrations do not occur in viral gastroenteritis.

16 Question 5 You are evaluating an 18-month-old boy in the emergency department who appears "toxic" and is sitting uncomfortably and leaning forward in his mother's lap. His temperature is 40.0°C, heart rate is 140 beats/min, respiratory rate is 35 breaths/min, blood pressure is 90/60 mm Hg, and oxygen saturation on room air is 94% by pulse oximetry. He is drooling from the corners of his mouth, and his cry appears muffled. The nurse shows you the lateral neck radiograph that was just obtained. Of the following, the MOST appropriate next step in the treatment of this patient is


18 A. administration of intramuscular penicillin B. blood cultures and a complete blood count C. emergent otolaryngology and anesthesia consultation D. intramuscular administration of dexamethasone E. throat culture

19 C Epiglottitis is a medical emergency. The incidence of this disease has significantly decreased since the introduction of the Haemophilus influenzae type b vaccine, and the most common infectious pathogens now are Streptococcus pneumoniae, group A beta-hemolytic Streptococcus, and Staphylococcus aureus. Often, the infection involves the entire supraglottic area, not just the epiglottis, and is called supraglottitis. Typically between 2 and 8 years of age, usually present with the rapid onset of fever, sore throat, and the "four Ds" (drooling, dysphagia, dysphonia, and dyspnea), "tripod position." Clinicians must be vigilant for atypical presentations, especially among children younger than 2 years of age.

20 AIRWAY!!! Direct examination of the airway under anesthesia An ETT that is 0.5 to 1 mm smaller than usual for age generally is needed. Cultures of the supraglottic area can be obtained at the time of intubation and broad-spectrum antibiotics: CTX. Lateral radiographs are diagnostic but should be deferred until personnel and equipment ready for airway security. As well as lab work, throat cx or IM meds. Neither penicillin nor dexamethasone is indicated for the initial treatment of epiglottitis Rifampin for 4 days for alll close contacs Children >2y/o no need for vaccine

21 Question 6 A 13-year-old girl who plays soccer presents with a temperature to 38.9°C for 2 days, dysphagia, malaise, and nausea. She has had no cough or rhinorrhea. Physical examination reveals erythema of the tonsils with petechial hemorrhages, petechiae on the soft palate, mild enlargement of the cervical lymph nodes, and vague discomfort in the epigastric area. On evaluation, you palpate a spleen tip. You obtain a rapid streptococcal antigen test and a throat culture. The rapid streptococcal antigen test is negative and you recommend antipyretics and rest. She returns to the clinic 48 hours later because her symptoms have not improved. The throat culture is negative, but the girl reports continued fever, increasing malaise, and some vomiting. Findings on the physical examination have not changed, and there are no signs of serious bacterial infection or dehydration. Of the following, the MOST efficacious next test for this patient is: A. CBC B. Epstein-Barr virus titers C. rapid influenza test D. spot test for infectious mononucleosis E. viral culture for adenovirus

22 D Criteria for streptococcal pharyngitis fever, sore throat, tender cervical lymphadenopathy, and NO cough. 70% of cases of exudative pharyngitis are due to virus. Petechiae on the soft palate may be a sign of group A streptococcal pharyngitis, but macules, vesicles, and other lesions of the palate also are seen in EBV, coxsackie and adeno Adenovirus : 25% of exudative pharyngitis, often with conjunctivitis. Enterovirus: pharyngitis, gastrointestinal complaints, and vesicular lesions of the pharynx, often including the palate. Arcanobacterium haemolyticum : bacterial cause of pharyngitis similar to by group A Streptococcus. Adolescents.

23 EBV: pharyngitis + more serious illness hepatosplenomegaly, hepatitis, or significant lymphadenopathy. Abdominal pain may be seen with streptococcal disease, Epstein- Barr virus infection, and a variety of other illnesses. R/o Kawasaki disease in the child who has fever and oral mucous membrane changes, especially with rash and adenopathy, as well as adenovirus and common rhinoviruses and influenza. For the girl described in the vignette, the heterophile antibody rapid mononucleosis spot test is likely to be helpful because it is widely available and results can be obtained quickly. If results are negative and clinical suspicion for this infection remains high, Epstein-Barr virus titers may be obtained. Standard adenovirus culture takes time, no fastest than 2 days, not readily available, and it can be in tonsills for months post infection. A haemolyticum may be cultured with conventional throat culture, but the laboratory must be informed The absence of cough or coryza in this patient makes Flu less likely. CBC not specific

24 Question 7 A 7 year-old-girl presents to your office with a 1-day history of a temperature of 38.9°C. Notable findings from her past medical history include static encephalopathy, seizure disorder, and recurrent urinary tract infections. She is receiving intermittent straight catheterization and trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis. Her medications also include phenytoin, albuterol via nebulizer, ipratropium, and ranitidine. Urinalysis reveals more than 100 white blood cells per high-power field and is positive for leukocyte esterase and nitrites. Of the following, the BEST option for oral empiric therapy pending culture results is A. Amoxicillin B. azithromycin C. ciprofloxacin D. Nitrofurantoin E. trimethoprim-sulfamethoxazole

25 C Recurrent UTI under TMP-SMX prophylaxis resistant pathogen, making ciprofloxacin,, the best option for therapy, pending cx and sensitivities. Azithromycin is not indicated for treatment of UTIs. Amoxicillin and nitrofurantoin not for resistant pathogen and no TMT-SMX because of resistance in this child Studies in young animals demonstrated arthropathy, but no increase incidence in pediatric pts The Committee on Infectious Diseases of the AAP suggest that fluoroquinolone use in pediatrics be restricted to situations in which the pathogen is multidrug-resistant and there is no safe and effective alternative or when parenteral therapy is not feasible and there is no effective alternative oral agent. Such situations might include UTIs caused by multidrug-resistant gram-negative rods, including Pseudomonas aeruginosa; gastrointestinal and respiratory tract infections caused by resistant gram- negative organisms; and chronic or acute osteomyelitis caused by P aeruginosa. In addition, a fluoroquinolone may be indicated for treatment or prevention of anthrax and for treatment of mycobacterial infection with sensitive strains. Be aware of interactions: antiacids containing aluminum, Mg or Calciumdecrease absorption of cipro, NSAIDS potentiate CNS side effects Cipro increases warfarin, inhibit K channels in heart and can cause long QT interval, hypo or hyperglicemia in pts with insulin

26 Question 8 An 18-month-old boy is brought to the clinic with fever and irritability. His mother explains that he has had a fever for the past week and a red rash on his extremities. On physical examination, he has a temperature of 39.2°C; he is irritable; his eyes are injected without discharge and his lips are dry, red, and cracked. All other findings are within normal limits. Of the following, the MOST appropriate next step in this patient's care is to: A. administer intravenous antibiotics B. administer intravenous gamma globulin C. obtain blood cultures D. obtain electrocardiography E. perform a lumbar puncture and culture the cerebrospinal fluid

27 B PLUS 4out of 5:

28 Vasculitis of small- and medium-sized blood vessels, including the coronary arteries. 80% of cases occur in children <4y/o > in winter and spring, > in males All ethnicities Phases: ACUTE: 1-2 wks after onset of fever and is when the diagnostic criteria typically are present. SUBACUTE: 2 to 8 weeks after disease onset, and patients may demonstrate desquamation of the fingers and toes. Coronary aneurysms may develop, particularly in those who have not been treated with intravenous gamma globulin during the acute phase. CONVALESCENT: lasts for months following the illness Because the child in the vignette is in the acute phase of KD, he should be treated with intravenous gamma globulin at a dose of 2 g/kg. If his fever persists, a second dose of gamma globulin may be administered. In addition, high-dose aspirin therapy (80 to 100 mg/kg per day) is administered until the patient is afebrile for 48 hours, at which time the dose is decreased to 3 to 5 mg/kg per day for 6 to 8 weeks or until the platelet values normalize. NO ABX, NO LP, NO EKG

29 Question 9 A 16-year-old girl comes to your office in August for evaluation of fever, headache with retro-orbital pain, and marked achiness of her joints and muscles. She returned 1 week ago from a church mission trip to El Salvador. A number of other people on the trip were diagnosed with a viral syndrome. Findings on physical examination are normal except for: T 39.1°C, HR: 104: Conjunctival injection without discharge Erythema of the pharynx without exudate Mild, tender hepatomegaly Maculopapular rash on the trunk and scattered petechiae Laboratory results include: WBC: 3.2x10 9 /L, Hb: 14, hct: 41.8%, platelets: 78 AST: 212 units/L, ALT: 187 units/L, Total bilirubin: 0.8 mg/dL BUN: 18.0 mg/dL, creatinine: 0.8 mg/dL Of the following, the MOST likely diagnosis is:

30 A. dengue fever B. Epstein-Barr virus infection C. hepatitis A infection D. Malaria E. typhoid fever

31 A retro-orbital pain, conjunctival injection, pharyngeal erythema, hepatomegaly with mild elevation of liver enzyme values, thrombocytopenia, and recent travel to El Salvador break-bone fever." Dx: serology Dengue virus is the most common arthropod-borne (arbo) virus disease in the world, Dengue fever has been reported in Southeast Asia, the South Pacific Islands, Latin America, and the Caribbean. Humans: accidental hosts

32 A Arbovirus: US: summer and autumn CNS involvement: West Nile virus, eastern and western equine encephalitis virus, St Louis encephalitis virus, LaCrosse encephalitis virus, and Japanese encephalitis virus. Other arthropod-borne illnesses include hemorrhagic fevers and febrile illnesses, often with rashes or hepatitis. Dengue fever is the most prominent of such infections. Others include Colorado tick fever and yellow fever

33 Infectious mononucleosis or acute Epstein-Barr virus infection can cause many of the symptoms and laboratory abnormalities (thrombocytopenia, elevated liver enzymes) described in the vignette, but the absence of splenomegaly and exudative pharyngitis and the extent of the myalgias and arthralgias are less typical of this condition. Similarly, the degree of systemic complaints is not consistent with hepatitis A infection. Malaria can present with many of the features described for this girl, but the degree of myalgias and arthralgias is somewhat severe for non-falciparum malaria, which are the types seen in Central America. In addition, anemia, hypersplenism, and pallor would be present in malaria. Furthermore, the viral illnesses reported in other members of the group are more consistent with a viral diagnosis than malaria. Typhoid fever also may manifest many of the complaints described for this girl, but the rash of typhoid (rose spots) is much more subtle, and abdominal pain generally is more prominent.


35 Q UESTION 10: A 15-year-old boy presents to the clinic because of a persistent cough. According to his mother, his cough has been present for approximately 2 weeks, but it seems to be getting worse. He does not cough all the time, but the coughing episodes tend to come in bursts. This morning she became very worried because he passed out during a coughing spell. Physical examination reveals a healthy-appearing male in no apparent distress. He is afebrile, and his vital signs are normal. He has petechiae on his face but no other skin lesions. His lungs are clear. Of the following, the MOST appropriate antimicrobial agent to prescribe for this patient is: A. azithromycin B. Clarithromycin C. Doxycycline D. Erythromycin E. trimethoprim- sulfamethoxazole Countdown 10

36 Pertussis (bordetella pertussis) Incubation: 3-12 days. A 6wk duration, with 3 stages lasting each one 1-2 wks. Stage 1: (catarrhal): URI symptoms Very contagious Stage 2: paroxysms of intense coughing lasting up to several minutes. Infants >6mo and toddlers: whooping cough cough, f/u by loud whoop as inspired air goes through a still partially closed airway. <6mo: apneic episodes and are at risk for exhaustion. Older children: Posttussive vomiting and turning red with coughing Stage 3: chronic cough, which may last for weeks. Older children, adolescents, and adults may not exhibit distinct stages. Symptoms in these patients include uninterrupted coughing, feelings of suffocation or strangulation, and headaches.

37 Dx: cough for >2wks + paroxysmal cough, posttussive vomiting, or inspiratory whoop Cx: nasopharyngeal swab for (15-30) or until cough

38 A Any patient who has episodic coughing that ends with syncope or vomiting consider pertussis Complications in adolescents: urinary incontinence, sleep interruption, rib fractures, and pneumonia. Despite vaccination: increase incidence in adolescents AAP: booster Tdap If received only tetanus toxoid or only Td, GIVE Tdap if the interval since the Td is > 2 years or if the adolescent is living in a setting of increased disease, immunosupression or risk to transmit to a vulnerable contact

39 Tx of pertussis after cough started DOESNT affect the course of the illness but limits the spread of disease to others. Macrolides: abx of choice Azithromycin Doesnt interact with drugs metabolized by citP450 Less side effects compared to other abx from same family TMT-SMX: if allergic to macrolides or macrolide-resistant isolate (child >2mo) Doxycycline is not recommended for the treatment of pertussis.

40 Question 11 You are speaking to the mother of a child who attends a junior high school where one of the students was diagnosed with meningococcal disease 24 hours ago. Her child does not have any classes with the index patient and, except for passing him in the hall during lunch 3 days ago, has had no other contact with the patient. The child's mother is frantic because the school sent home a notice asking parents to bring their children to the public health department or their private physician to receive antibiotic prophylaxis. Of the following, the MOST appropriate advice for this parent is that her child: A. does not require antibiotic prophylaxis and does not need to be seen B. does not require antibiotic prophylaxis but needs to be evaluated to determine if she is developing symptoms of meningococcal disease C. needs to be seen to obtain nasopharyngeal cultures for meningococcal organisms and if the cultures are positive, may require antibiotic prophylaxis D. requires antibiotic prophylaxis and should be seen immediately E. should be seen immediately to determine if she needs to be hospitalized and treated for possible meningococcal disease Countdown 10

41 A Classroom contacts of students who have meningococcal disease, are considered CASUAL contacts (no history of direct exposure to the index patient's oral secretions), and the use of prophylactic antibiotics is NOT recommended. Prophylaxis: Close contacts of all persons who have invasive meningococcal disease, whether sporadic or in an outbreak, SHOULD receive chemoprophylaxis within 24 hours of diagnosis of the primary case, regardless of vaccination status. Close contacts include ALL household contacts, child care and nursery school contacts during the previous 7 days, persons who have had direct contact with the patient's oral secretions, and persons who frequently eat or sleep in the same dwelling as the index patient. In view of this and the fact that the contact is asymptomatic, she does not require medical evaluation at this time, and nasopharyngeal cultures are not indicated.

42 Because secondary cases of meningococcal disease can occur several weeks after the onset of disease in the index case, the use of meningococcal vaccine is a possible adjunct to chemoprophylaxis if the serogroup is contained in the vaccine. Other infections can spread easily in the household setting and may require the use of postexposure prophylactic immunoglobulin, antibiotics, or vaccines to prevent development of disease in individuals exposed to the index case, such as:


44 Question 12 A 2-year-old girl presents to the emergency department with a simple febrile seizure. After the recovering from their shock, the parents, who are medical students, ask you whether genetic predisposition or particular infectious agents confer risk for febrile seizures. You respond that several genes appear to increase risk for febrile and nonfebrile seizures, but certain infectious agents also may be more likely than others to trigger febrile seizures. Of the following, the agent that is MOST associated with febrile seizures is: A. Aspergillus fumigatus B. Escherichia coli C. group A beta-hemolytic Streptococcus D. human herpesvirus type 2 E. human herpesvirus type 6 Countdown 10

45 E Febrile sz: Common: 1mo to 5 years, often: presenting between 6 months and 3 years of age. > benign Predispositions are not fully characterized but include both genetic factors and types of infections URI, AOM, roseola (HHV 6) HSV 2, group A beta-hemolytic streptococcal infection, aspergillosis, and Escherichia coli infections have NOT been linked to febrile seizures.

46 Question 13 A 9-year-old girl presents to the ED because of fever, a macular rash on her trunk and arms, and pain in her knees and ankles. Her mother explains that she recently had pharyngitis. You note a murmur on physical examination and order electrocardiography and echocardiography. The echocardiogram demonstrates mitral regurgitation.


48 Of the following, the MOST likely diagnosis for this girl is : A. acute rheumatic fever B. cat-scratch disease C. Epstein-Barr viral infection D. Lyme disease E. SLE Countdown 10

49 A The girl described in the vignette has three of the five major Jones criteria for the diagnosis of acute rheumatic fever. Complications:: Carditis: lead to mitral and ocassional aortic regurgitation and stenosis. Migratory arthritis and chorea will resolve with no problems Best evidence of strep infection: elevated ASO or antiDNAase B titer. Tx: steroids if severe carditis leading to CHF.; unclear if reduces long term valve dysfunction. ASA can shorten acute symptoms, but unclear if decrease the risk of serious lifelong rheumatic heart disease. The MOST important chronic therapeutic intervention is antibiotic prophylaxis to prevent group A streptococcal pharyngitis, which can lead to a recurrent bout of acute rheumatic fever. Serious valve damage is unusual after the initial attack of acute rheumatic fever but becomes more likely with subsequent attacks. Administration of intramuscular benzathine penicillin every 21 to 28 days Rheumatic fever prophylaxis must continue into adulthood.

50 Jones criteria: ARF (2 major OR 1 major and 2 minor, + evidence of a preexisting Group A hemolytic streptococcal infection)

51 Why not? Cat-scratch disease : by Bartonella. Most commonly in children 1 to 2 weeks following a cat scratch or bite. Common findings are lymphadenopathy, headache, chills, and abdominal pain. The disease usually resolves spontaneously, with or without treatment, in 1 month. Cardiac valve involvement and electrocardiographic changes are rare.

52 Why not? EBV infection infectious mononucleosis, which develops when a person initially is exposed to the virus during or after adolescence. Symptoms : fever, pharyngitis, hepatitis, and lymphadenopathy. Usually, laboratory tests are needed for confirmation. Serologic results include an elevated white blood cell count, an increased percentage of certain atypical white blood cells, and a positive reaction to a "mono spot" test. Pericarditis and myocarditis are infrequent findings. The young age of the patient in the vignette is highly unusual for symptomatic Epstein-Barr virus infection, as are the electrocardiographic changes, rash, and arthritis.

53 Why not? Lyme disease results in fever, rash, malaise, and muscle soreness. Although neurologic disorders and arthritis can occur, these are invariably late findings. In addition, the morphology of the rash distinguishes this condition from acute rheumatic fever, and the Jones criteria are not fulfilled. Carditis is a rare manifestation of Lyme disease. The most common abnormality is atrioventricular block of various degrees, although other rhythm abnormalities have been reported. Pericarditis, myocarditis, cardiomyopathy, and degenerative valvular disease have been associated with Borrelia burgdorferi infection.

54 Why not? Systemic lupus erythematosus (SLE) can present with rash, carditis, and arthritis. However, evidence of a preexisting group A hemolytic streptococcal infection would not be expected. Of course, this laboratory finding could be present in a patient who has SLE, but these two diagnoses can be distinguished by the additional laboratory findings in SLE, including antinuclear antibody, anti-double-stranded DNA antibodies, and low complement values.

55 Question 14 A 14-year-old otherwise healthy boy developed an oval pink, scaly lesion on his back about 1 week ago. He presents today with widespread, moderately pruritic, scaling macules involving his trunk and upper extremities but sparing the scalp, face, palms, and soles. He admits to being sexually active but has no other known exposures and takes no medications. Aside from the rash, physical examination findings are normal.


57 Of the following, the MOST appropriate next step in management is to: A. obtain serology for Mycoplasma and Legionella B. obtain serology for syphilis C. perform a skin biopsy D. prescribe a course of azithromycin E. prescribe a topical antifungal cream Countdown 10

58 This pt has: PYTIRIASIS ROSEA! INFLAMMATORY SKIN CONDITION, MOSTLY ADOELSCENTS, OF UNKNOWN ETIOLOGY PRODROME: URI LATER: HERALD PATCH: 2-10cm oval, red flat, scale, can get confused with tinea corporis or atopic dermatitis. THEN: 2-21 days after the appearance of the herald patch, crops of 5- to 10-mm oval, salmon-colored thin plaques appear. These range in number from less than 50 to more than 200 on the body. They are classically distributed along Langer's lines, producing a Christmas (fir) tree pattern on the back. They also may appear transversely across the lower abdomen and back, circumferentially around the shoulders, or in a V-shaped pattern on the upper chest. African-american: more in face RESOLVES: in 2-12wks ? Association with HHV-7, Legionella, Mycoplasma.

59 B Among the most important differential diagnoses for pityriasis rosea is secondary syphilis, especially is rash on palms and soles. In rare occasions when rash doesnt resolve, consider skin bx. TX for pytiriasis rosea; Pruritus: emollients No evidence of improvement with topical antifungal ? With macrolides help decrease duration of disease

60 Question 15: A 14-month-old boy presents to the emergency department for evaluation of respiratory distress, recent fever, cough, and congestion. He has received all of his vaccinations. Physical examination shows tachycardia, poor perfusion, and hepatomegaly. CXR documents an enlarged heart with hazy lung markings. Electrocardiography reveals sinus tachycardia. Echocardiography identifies severe left ventricular dilation and systolic dysfunction, with mitral regurgitation. You suspect dilated cardiomyopathy. Of the following, the MOST likely cause is: A. bacterial pneumonia leading to bacterial myocarditis B. congenital coronary artery anomaly C. Duchenne muscular dystrophy D. previously undetected supraventricular tachycardia E. viral myocarditis due to enterovirus Countdown 10

61 E Myocarditis, most often is due to infection from common viruses. Inflammation myocite necrosis dilated cardiomyopathy Symptoms: fever, chest pain, abd pain, peripheral edema, resp distress, liver congestion, palpitations. Toddlers: decrease po, cough, malaise Complications: CHF, poor cardiac output, arrhythmias, pericarditis, death Suspicion: elevated ESR, CRP, troponin, echo cardio + for LV dilatation, myocardial edema. Gold standard: myocardial bx.

62 ETIOLOGY: INFECTIOUS: Enterovirus, coxsackievirus, adenovirus, parvovirus B19, HIV and cytomegalovirus. Bacterial causes are rare, except for patients who have immunodeficiency (Brucella, Corynebacterium diphtheriae, Haemophilus influenzae, and Borrelia burgdorferi (Lyme disease) as well as Fungal pathogens TOXINS: ethanol,CO, anthracyclines chemotherapy, some antipsychotics (eg, clozapine), and immunologic reactions to acetazolamide and amitriptyline AUTOIMMUNE: sleroderma, SLE Treatment: symptomatic: inotropes, afterload reduction, diuretics High inflammatory markers: IVIG and steroids Maintenance: ACE-captopril CHF: heart transplant

63 Congenital coronary anomalies can cause myocardial dysfunction and subsequent isquemia such as: coronary fistula Anomalous coronary artery arising from the pulmonary artery Will present with similar symptoms but no URI prodrome Duchenne muscular dystrophy results in a dilated cardiomyopathy, but changes until late childhood or early adolescence. Supraventricular tachycardia (in addition to all forms of atrial tachyarrhythmia) can cause a dilated cardiomyopathy if it is chronic

64 Question 16: A 17-year-old girl has been hospitalized for 3 weeks due to complicated peritonitis following a ruptured appendix. She has undergone laparotomy and drainage of intra- abdominal abscesses and improved while receiving intravenous ampicillin, gentamicin, and clindamycin. Her nasogastric tube was removed last week, and she has been tolerating a bland diet. Today, however, she complains of abdominal pain and distention and has had three episodes of diarrhea. Physical examination reveals a febrile adolescent who has a diffusely tender abdomen. Of the following, the stool test MOST likely to establish the diagnosis is: A. bacterial culture B. evaluation for ova and parasites C. fecal occult blood D. toxin assay E. viral culture Countdown 10

65 D Long course of IV abx + abd pain+ diarrhea = colitis sec to Clostridium difficile. Dx: stool for C difficile toxins (A and B). If sample will not be tested promptly, store it at 4°C (deteriorates at room temperature) Endoscopy: Pseudomembranes and friable colorectal mucosa. Occult blood would not be diagnostic A stool study for ova and parasites would not be useful because a patient who has been hospitalized for a prolonged period of time is unlikely to have developed a gastrointestinal tract infection due to a parasite. Nosocomial viral infections of the gastrointestinal tract do occur, and a stool viral culture may be appropriate but in this case, hx is more related to C diff. The spectrum of illness caused by C difficile ranges from asymptomatic carriage to watery diarrhea to pseudomembranous colitis. Asymptomatic carriage can occur at any age but is common in newborns and <1y/o.

66 C diff Symptoms: fever, abdominal pain and cramps, and diarrhea and appear systemically ill. Complications: Toxic megacolon and intestinal perforation likely to be fatal in infants who have underlying gastrointestinal disease (Hirschsprung disease or inflammatory bowel disease) or are immunocompromised. Risk factors : Abx therapy (especially beta-lactam drugs, clindamycin, fluoroquinolones, and macrolides ), BUT CAN HAPPEN WITH ANYONE), underlying bowel disease, gastrointestinal tract surgery, prolonged nasogastric tube insertion, repeated enemas, and renal insufficiency. Prolonged hospitalization, rooming with an infected patient, and being on the same hospital ward as a symptomatically infected patient Prevention: hand hygiene, limiting antibiotic use, properly disposing of contaminated materials, and adequately cleaning contaminated surfaces. Alcohol-based hand hygiene products and many common hospital disinfectants do not eradicate C difficile spores; USE SOAP AND WATER Diluted bleach solutions are best for cleaning and decontaminating surfaces. Excluded pt from group activities for the duration of the diarrhea. Tx: Metronidazole orally or intravenously is effective and the drug of choice. Oral vancomycin for patients who have severe disease or can be used alone for those who do not respond to metronidazole. Therapy should be administered for at least 10 days.

67 Question 17: A 3-year-old boy developed a petechial rash beginning on his wrists and ankles 5 days after a family camping trip in the Chesapeake Bay area. A latex agglutination assay confirms the diagnosis of Rocky Mountain spotted fever. Of the following, the MOST appropriate antibiotic choice for treating this child is: A. Amoxicillin B. Azithromycin C. Chloramphenicol D. Doxycycline E. trimethoprim- sulfamethoxazole Countdown 10

68 D Amoxicillin, azithromycin, and trimethoprim- sulfamethoxazole are not active against Rickettsia rickettsii, the etiologic agent of RMSF. Other uses for tetracyclines: chlamydial infections (eg, nongonococcal urethritis, pelvic inflammatory disease), Lyme disease, community-acquired MRSA Legionnaires disease, Mycoplasma infections, leptospirosis, chloroquine-resistant malaria, and traveler's diarrhea. Doxycycline is the treatment of choice for Rocky Mountain spotted fever (RMSF)

69 Question 18: A 9 y/o boy has complained of stomach cramps and diarrhea for the past 3 days. Five days ago, he visited a dairy farm with his 4 th grade class and drank unpasteurized milk. A fecal sample brought in by the parents demonstrates mushy stool, with flakes of mucus and blood. Findings on PE include a HR of 110, dry lips, mild and diffuse nonspecific abdominal tenderness; and active bowel sounds. You hospitalize the boy for administration of IVF and send a stool specimen for culture. Of the following, a TRUE statement about AGE is that : A. Cats and dogs are not at risk for human infection with enteric pathogens B. Erythromycin shortens the duration of Campylobacter gastroenteritis C. Rotavirus is a common cause of bloody diarrhea in infants and children D. The incubation period for calicivirus (norwalk) is 5-7 days E. TMP-SMX is the tx of choice for Giardia lambia infection Countdown 10

70 B Acute onset of symptoms, unpasteurized milk consumption and stool findings= acute bacterial colitis Common pathogens: Campylobacter, Salmonella, Shigella, Yersinia, E. coli, C. diff. > bacterial gastroenteritis have an incubation time of 1-7 days after exposure Transmission: Cats and dogs: giardia Tx with metronidazol or nitazonamide Rotavirus: no blood, infants Norwalk: incubation 12hrs-4 days Other diff dx: IBD, HSP, vasculitis. Meckel and polyps: blood but painless Or Campylobacter: improperly cooked poultry and … Erytho or azithro decrease duration of illness If stool + for C fetus: septisemia-meningitis: IV abx


72 Question 19 A 5 y/o girl has been bitten on the hand by her cat. Within 24hrs of the bite, she developed pain, edema and erythema at the bite site. Of the following, the MOST likely organism to cause the wound infection is: 1. Alpha-hemolytic streptococcus 2. Bacteroides 3. Fusobacterium 4. Pasteurella multiocida 5. Staphyloccus aureus Countdown 10

73 D Bites: > dogs then cats But higher rate of infection (sharp teeth=puncture wound=deep inoculation) Tx: careful cleaning tetanus prophylaxis if required evaluation for need for rabies prophylaxis use of abx if wound is infected

74 Pasteurella multiocida Infection: quick <24hrs, erythema, tenderness and edema Tx: Augmentin-cover also for anaerobes and S. aureus DONT USE: cephalexin, clinda, cefaclor, cefadroxil= resistant If allergy to PCN: use TMP-SMX, cefuroxime

75 Tetanus prophylaxis WoundTetanus (3 doses)Tetanus unknown contaminatedNone (if last tetanus was <5yrs ago) TIG + Tdap cleanNone ( if last tetanus was <10yrs ago) Tdap Dtap if < 7y/o

76 Rabies prophylaxis Transmitted to humans and domestic animals from infected bats, raccoons, skunks, foxes, and coyotes. Mice and rabbits: rare Transmission: contamination of mucosa or skin lesions by saliva or neural tissue from the infected animal. Incubation period of the virus ranges from a few days to years but usually is 4 to 6 weeks.

77 In cases where animal testing is not possible Give: rabies immune globulin (RIG) and rabies vaccine ideally within 24 hours of exposure Give RIG within 7 days: Protect against rabies between exposure and antibody production Total: 20 IU/kg of RIG, > around the wound, remaining, give IM at a distant site from the vaccine.

78 Rabies vaccine 1 mL IM dose in the deltoid muscle or the anterolateral thigh on the day of exposure or first day of postexposure prophylaxis (day 0) and is repeated on days 3, 7, and 14 after the initial dose in immunocompetent individuals. For immunosuppressed individuals, an additional 1.0- mL dose of vaccine should be provided on day 28 of postexposure prophylaxis. Documentation of seroconversion 1 to 2 weeks after the completion of prophylaxis is reserved for immunosuppressed persons. Animal Bite Report Form

79 Question 20 You are asked to attend the delivery of a term infant because the baby is SGA and prenatal US revealed periventricular cerebral calcifications. The infants bwt: 2 kg. On PE, you note HSM and a petechial rash on face and trunk.


81 Of the following the BEST laboratory test for dx the cause of these findings is: 1. Nasopharyngeal cx for HSV 2. RPR for syphilis 3. Serum IgG for rubella 4. Serum IgM for toxoplasmosis 5. Urine cx for cytomegalovirus Countdown 10

82 E All viral specimens: transported on ice Easy to identify: adeno, HSV, VZV, CMV, entero, rhino, influenza, parainfluenza, RSV Newborns: asymptomatic: HSV, syphillis Cerebral calcifications: NONE: Rubella-Cataracts + glaucoma tx: none PERIVENTRICULAR: CMV-chorioretinitis tx? gancyclovir DIFFUSE: toxoplasma tx with pyrimethamine, sufadiazine, leucovorin All have HSM and petechial rash No hearing loss in toxo Dx: CMV with urine cx

83 Question 21 You are called to help manage a 2y/o girl who has relapse ALL and has developed enteroccal bacteremia. Initial susceptibility testing reveals that the pathogen is resistant to vancomycin. Upon further investigation, you discover that the infecting organism is Enterococcus gallinarum. Of the following, the MOST effective antimicrobial agent for this infection is: 1. Ampicillin 2. Ciprofloxacin 3. Linezolid 4. Ticarcillin 5. Vancomycin Countdown 10

84 A Ampicillin is the most active B-lactam antimicrobial agent against most enterococcal isolates Enteroccus SHOULD BE considered resistant to cephalosporins, aminoglycosides, ciprofloxacin and TMT/SMX E. gallinarum and Ecasseliflavus: vancomycin resistant Linezolid: can be used for vanco-resistant bacteria but few data in children

85 Question 22 Among the following, the condition that is MOST likely to predispone a pediatric patient to the development of systemic candidiasis is? 1. History of atopy 2. Hx of prematurity 3. Immunosupression 4. Presence of indwelling urinary catheter 5. Recent tonsillectomy Countdown 10

86 C Of the opportunistic infections in children, candida is the most common Candidiasis: blood + disseminated infection Candidemia: blood + localized to central venous catheter Risk factors: Immunosupression: cellular (CHEMO PTS) Broad spectrum abx Extensive burns Long term TPN Prematurity + comorbilities + poor nutritional status+ abx Alone NO RISK

87 No RISK: Atopy Indwelling urinary catheter: bacterial Sx: exc if extensive and pt immunodepressed

88 Question 23 A woman suffers a brief flu-like illness during he 34 th wk of pregnancy and goes to labor. She delivers a 2.2kg baby who rapidly develops hypotension, respiratory distress and apnea. Finding include: fine, white nodules on the fetal surface of the placenta and thrombocytopenia. The most likely etiology of these findings is? 1. C. botulinum 2. E. coli 3. GBS 4. Listeria 5. S. aureus Countdown 10

89 D Listeria: Gram + nonspore-forming rod Early: 1 wk: sepsis: shock, hypothermia, rsp distress, lethargy, apnea, metab acidosis, leukocytosis or neutropenia, thrombocytopenia) Late: 2wks: meningitis flu-like illness on mother 1-2 wks prior to delivery+ nodules in placenta (microabscess) Hx of miscarriages or stillbirths in mother In severe cases baby develops microabscess in internal organs as well as on skin Tx: ampicillin + gentamycin for 14 days NO CEPHALOSPORINS: resistant

90 GBS Gram + diplococci NO active disease in mom, prolonged asymptomatic carriage Risk factors: PT <37wk prolonged ROM > 18hrs infants born to women with high genital GBS inoculum intrapartum fever Chorioamnionitis GBS bacteriuria during the current pregnancy previous infant with invasive GBS disease. A low or an undectable maternal concentration of type-specific serum antibody to capsular polysaccharide of the infecting strain. = ~ to listeria with acute and late onset (but this also includes: osteomyelitis, septic arthritis, cellullitis) SCREENING: 35-37wk (vaginal and rectal) Chemoprophylaxis: with Penicillin G 5 million U initially, then 2.5 to 3.0 million U, every 4 hours, until delivery

91 Remember: If GBS status is unknown at onset of labor or ROM, give intrapartum prophylaxis to ALL women with gestation less than 37 weeks, duration of membrane rupture 18 hours or longer, or intrapartum temperature of 38.0°C (100.4°F) or greater + GBS bacteriuria is enough for tx No prophylaxis in C/S

92 a full workup: CBC, blood cx. CXR, LP –if septic d Limited evaluation includes: blood cx. CBC f If sepsis develop, do full workup + abx g If 37 weeks' gestation, observation may occur at home after 24 hours if other Management of Neonates for Prevention of Early-Onset Group B Streptococcal (GBS) Disease. RED BOOK guidelines

93 Question 24 A 2y/o F who has congenital hydrocephalus and a VPS has a T.102, irritability, vomiting for 3 days. She now has nucchal rigidity. Examination of CSF taken from the shunt reveals WBC 50, N: 65% and L 35% and a few Gram + cocci in clusters. The best abx to given this pt is? 1. Cefotaxime 2. Cefuroxime 3. Nafcillin 4. Penicillin 5. vancomycin Countdown 10

94 E Pt has a shunt-related ventriculitis Staphylococcus epidermidis (coagulase neg) or S. aureus (coagulase positive) VANCOMYCIN: bacteridal exc for enterococci

95 Question 25 Physical exam of a 6wk old afebrile infant reveals a RR 74, and few crackles on inspiration. The 17y/o mother reports that the infant has had a loud cough but otherwise has been well except for some yellow eye drainage last week. The mother recently was treated for an infection in the genital area. Among the following, the MOST likely cause of the infants findings is? 1. B0rdetella pertussis 2. Chlamydia trachomatis 3. Influenza type A virus 4. RSV 5. Streptococcus pneumoniae Countdown 10

96 B Infants < 3months old with cough WITHOUT fever and a purulent eye discharge should be suspected of chlamydia trachomatis infection until proven otherwise Tachypnea, resp distress, crackles, NO wheezing Staccato cough 50% purulent conjuntivitis 50% otitis LAB: eosinophilia, increased serum Igs TX: Infants with chlamydial conjunctivitis or pneumonia oral erythromycin base or ethylsuccinate for 14 days or azithromycin for 3 days

97 Who to screen for chlamydia?- high risk Women with mucopurulent cervicitis Sexually active women <20y/o > than 1 sexual partner in 3 months Women who used barrier contraception inconsistently while in a nonmonogamous relationship Men with dysuria + urethral d/c 7-14 days after contact

98 Question 26 A 15 mo F who recently returned from visiting her grandmother in the Caribbean is found to have ascarisis. Of the following the best treatment is? 1. Iodoquinol 2. Metronidazol 3. Praziquantel 4. Pyrantel pamoate 5. thiabendazole Countdown 10

99 D 1 dose of pyrantel pamoate Also willl work: mebendazole x 3d OR albendazole 1 dose but NOT studied in kids < 2y/o Iodoquinol: entamoeba histolytica Metronidazole: Giardia lambdia, E. hystolytica, trichomocnas vaginalis Praziquantel: schistosoma, tapeworm Thiabendazole: strongyloides, cutaneous larva migrans

100 Question 27 A 9 mo boy was exposed 5 days ago to a child who has confirmed rubeola. Among the following, the intervention that is MOST likely to prevent measles in the exposed child is administration of? 1. Acyclovir 2. IM immunoglobulin 3. IV immnunoglobulin 4. MMR vaccine 5. MMR vaccine + IM immunoglobulin Countdown 10

101 B The risks for complications as a result from measles is high among infants <1y/o Immunoglobulin given within 6 days of exposure can prevent or modify the disease. Prefer IM (0.25ml/kg) IV: has same concentration, but higher cost In an outbreak situation or if the exposure to measles occurred within the previous 72hrs, administer MMR vaccine to infants as young as 6mo old.

102 Question 29 During an emergent evaluation of a 7y/o girl with slurred speech, ataxia and gralized hypotonia, you note brief rapid, jerking movements of the limbs and face. She is alert and oriented. Examination of the cranial nerves is normal. Deep tendon reflexes are 2+ and symmetrical in the upper and lower extremities. Which of the following cutaneous findings is most likely to be identified in pts with similar signs and symptoms? 1. A blotchy, gralized erythematous, blanching macular rash 2. Erythematous, nontender, circumscribed patches over the cheeks, sparing the perioral region 3. Several patches of grouped thick-walled vesicles on an erythematous base, some of which have become ulcerated in appearance 4. Generalized desquamation of the skin characterized by large, thin flakes, especially prominent in the groin and axilla 5. A gralized purpuric and petechial rash Countdown 10

103 D Girl with sudden onset of chorea + hypotonia + speech difficulty= sydenham chorea Uncontrollable, with complete inability to ambulate Sudden decrease in school performance (dramatic change in handwritting) facial grimmacing thrusting tongue movements Uncharacteristic irritability, emotional lability Can present inmmediately after strep infections or months later Skin characteristics (desquamation in groin and axilla) follows 5-7 days after sandpaper rash

104 Scarlet fever Measles Erythema infectiosum-5 th disease Herpetic whitlow Meningococcimia

105 Question 30 A 15y/o F with turner syndrome and a hx of bicuspid valves presents with fever, extreme fatigue, anorexia and malaise. Her Temp On PE, a previously noted systolic ejection click is associated with a new harsh ejection murmur. Additional clinical findings include mucous membrane and extremity petechiae and blanching painless erythematous lesions on the palms and soles. Which of the following is the most likely cause of this pts clinical signs and symptoms? 1. A 15y/o F with turner syndrom e and a hx of bicuspid valves presents with fever, extreme fatigue, anorexia and malaise. Her Temp On PE, a previousl y noted systolic ejection click is associate d with a new harsh ejection murmur. Addition al clinical findings include mucous membra ne and extremit y petechia e and blanchin g painless erythem atous lesions on the palms and soles. 2. Which of the following is the most likely cause of this pts clinical signs and symptom s? 1. S. pneumoniae 2. Viridans streptococci 3. E. coli O157:H7 4. Neisseria meningitides 5. H. influenzae type b Countdown 10

106 B Subacute bacterial endocarditis S. aureus >> s. viridans>> coagulase neg staph>> GBS and GAS If suspicion: f/u blood cx for 7 days (fastidious bacteria or fungi) At least 3 blood cx > of SBE in children >2y/o have a preexisting structural cardiac abnormality (bicuspid aortic valves, septal defects, coarctation of aorta, TOF, a prosthetic valve) and present with new or worsening murmur.

107 Skin manifestations Osler nodes: painful nodules on the pulp of finger or toes Splinter hemorrhages: non blanching, linear red-brown beneath nail beds Roth spots: edematous hemorragic lesions within retina Janeway lesions: red macular blanching palms and soles-painless

108 Question 31 A 6y/o girl presents with the sudden onset of brief, purposeless movements of her arms and legs associated with generalized hypotonia and irritability. Results of laboratory evaluation include include a markedly elevated ASO (antistreptolysin) level. Which of the following is most likely to be identified in this patient? 1. Repetitive hand wringing and sighing respirations 2. Involuntary apposition of the thumb and visible contraction of the muscles of the thenar eminence upon percussion of the thenar eminence with a reflex hammer 3. Intermittent episodes of painful blanching, followed by cyanosis and then hyper-erythema of the fingers and toes 4. Delayed relaxation of the fingers when asked to grip the examiners fingers and release rapidly 5. Repetitive relaxation and tightening of the hand when asked to shake hands with the examiner Countdown 10

109 E Recent GAS Sydenham chorea:chorea milkmaids grip Relaxation and tightening handshake spooning darting tongue Inability to protrude the tongue for more than a few seconds pronator sign Outward movement of the arms and palms when held above the head

110 Hand wringing and sighing respirations: Rett Involuntary apposition of thumb+contraction thenar eminence muscles upon percussion with hummer +delayed relaxation: myotonic dystrophy Intermittent episodes of blanching cyanosis hyperemia: Raynaud phenomena

111 Question 32 A 4y/o boy presents with a 1 wk hx of painful bowel movements that have caused him to attempt to withhold his stool and refrain from using the bathroom. He complains of persistent perirectal pain and mild associated pruritus. On PE, a flat, well demarcated, tender, intensely erythematous and moist perianal eruption, associated with a perianal fissure is noted. Which of the following is the most appropriate next step in the treatment of this patient? 1.Oral penicillin 2.Oral polyethylene glycol 3.Topical nystatin powder 4.Topical acyclovir cream 5.Topical corticosteroid cream Countdown 10

112 A Perianal streptoccal dermatitis Associated constipation Voluntary whitholding Peaks at 4-5y/o > in boys Associated with symptomatic or asymptomatic GAS colonization in the throat Unexpected flare of psoriasis Tx: oral penicillin

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