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Pediatric Notes For Third Year Shelf PDF
Pediatric Notes For Third Year Shelf PDF
2015
PEDIATRIC NOTES
Outline + Q&A's
Key:
Appeared once, twice, three, four, five, six, seven, eight, and nine times in Question Banks as main
symptom or deciding factor for a question
Tx = Treatment
Dx = Diagnosis
William Martin
OC USN
2.23.2015
Neonatology
Pulmonary
Cardiology
Gastroenterology
Infectious Disease
General/Random Info
William Martin
OC USN
2.23.2015
Neonatology
Neonatal Tooth
o If loose, can fall out and be aspirated
Extraction by pediatric dentist
o Midline or pointed tooth can be associated w/ genetic syndromes
Sturge-Weber Syndrome
o Vascular cutaneous malformation w/ trigeminal distribution
Port wine stain (Facial Angioma)
Also involves meninges
Seizures, MR, contralateral hemiparesis
o Choroidal angiomas
Twin to Twin Transfusions
o 15% of monochorionic twins
o S/Sx
Hct difference of 15% between twins
Recipient
Polyhydraminos, plethora, Hct, hyperviscosity syndrome,
hyperbilirubinemia
Polydactyl
o Postaxial (5th finger side)
Normal occurrence in AA
Surgical removal
Abnormal in whites
Careful cardiac exam
o Preaxial (thumb)
Abnormal in all races
Investigate further
o Associated w/ Trisomy 13
Cleft Lip and Cleft Palate
o Complications
Recurrent otitis media
Hearing loss
Speech defects
William Martin
OC USN
2.23.2015
o Tx
Repair
Lip
o 2-3m
Palate
o 6m to 5y
Propranolol (during pregnancy)
o Causes growth retardation, hypoglycemia, apnea
o ability of asphyxiated newborn to HR/CO
Opioid (Narcotics) in Newborn
o Hx of maternal narcotic use
Demerol for labor pain control
Heroin
o S/Sx
Lethargic, limp, depressed respirations
o Tx
Manage ABCs
Naloxone
Subgaleal (or subaponeurotic hemorrhage)
o S/Sx
Similar feel to cephalohematoma (squishy), crosses midline (entire scalp),
fluid wave
Rapidly expands
Signs of hypovolemia from hemorrhage
Tachycardia
o Tx
Careful monitoring, transfer to NICU
Erb-Duchenne Palsy
o Cervical nerves 5 and 6
o S/Sx
Unable to abduct, externally rotate, or supinate
Arm will remain internally rotated at side w/ forearm protonated
Wont move w/ Moro reflex
o May coexist w/ phrenic nerve palsy (Cervical nerves 3,4,5)
Ipsilateral hemiparesis of the diaphragm
Asymmetry on inspiration when it doesnt flatten
See Saw
Typically resolves on own
Clavicle Fracture
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
OC USN
2.23.2015
Postnatal hematoma
Poland Syndrome
o Chest asymmetry from agenesis of pectoralis
Periodic Breathing
o Normal in preterms
Irregular breathing w/ short apenic bursts 5 to 10s
Umbilicus
o 2 arteries, 1 vein
1 artery suggests renal malformation
Diastasis Recti
o Separation of the rectus abdominis @ midline
o Benign
Umbilical Hernia
o Soft swelling beneath umbilicus
o May protrude during crying
o Most close spontaneously
Persistent Urachus
o Urine draining from bladder to umbilicus
Hydrometrocolpos
o Cysts between the labia
Caused by an imperforate hymen and collection of secretions behind
Male Genitalia
o Hypospadias
Urethral Meatus Ventral
Not associated w/ incidence of urinary malformations
o Epispadia
Urethral Meatus Dorsal
Often associated w/ bladder extrophy
Protrusion of bladder from abdominal wall, w/ exposure of its mucosa
o Hydrocele
Scrotal swelling
Fluid in tunica vaginalis
Resolve spontaneously
o Cryptorchidism
Surgery should not take place < 1 y/o
Typically descend by 12m
o If fails risk of malignancy
Surgical correction after 1 y/o
Extremities
William Martin
OC USN
2.23.2015
o Absence/Hypoplasia of Radia
TAR Syndrome (thrombocytopenia, absent radii), Fanconi Anemia, Holt-Oram
Syndrome
o Edema of feet w/ hypoplastic nails
Turner Syndrome & Noonan Syndrome
o Rocker Bottom Feet
Trisomy 18
Post term (>42w)
o Placental insufficiency
Intrauterine asphyxia, meconium aspiration, polycythemia
Small for Gestational Age (SGA)
o Complications
Hypoxemia, perinatal asphyxia, hypocalcemia
Hypomagnesaemia
Floppy
Polycythemia (>65% Hct)
From erythropoietin in response to hypoxia
blood viscosity
o hyperviscosity syndrome
Jittery, seizures
Changes in cerebral blood flow
Renal V. thrombosis
NEC
Tx
o Partial exchange fusion
Hypothermia
From ability to thermoregulate from subq fat
Hypoglycemia
From glycogen stores
Manage w/ early and frequent feeds
o Associated w/ higher incidence of major congenital abnormalities
Large for Gestational Age (LGA)
o Causes
Diabetes, Beckwith-Wiedmann Syndrome, Prader-Willi Syndrome,
Nesidioblastosis (diffuse proliferation of pancreatic islet cells)
Cyanosis
o Related to the amount of unoxygenated Hb
>3 arterial or >5 capillary
o Causes
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
Especially w/ C section
o Meconium Aspiration Syndrome (MAS)
Especially post term
Persistent Pulmonary HTN (PPHN)
o Any condition other than CHD w/ low blood flow to the lungs after birth
o Causes
Perinatal asphyxia
Can result in pulmonary pressure while the systemic BP falls
o Causes a persistent R to L shunt across PDA or PFO
Results in PPHN
MAS (meconium aspiration syndrome)
Any cause of fetal stress
o PVR
RL Shunt through PFO or PDA
o Cyanosis from Respiratory Failure
o Pre and Post Ductal PO differences
o CXR
????????????????????
o Echo
Rule out CHD, assess shunt
o Tx
O
Important b/c hypoxemia is a potent vasoconstrictor (want to PVR)
NO
Meconium Aspiration Syndrome (MAS)
o Respiratory distress in term or post term newborn
o Pea Soup or Meconium stained amniotic fluid
o Meconium (first stools)
Can be passed as result of distress (e.g. hypoxemia)
o CXR
Lung Vol, diffuse patchy atelectasis, parenchymal infiltrates alternating w/
hyperinflation
Possible pneumothorax
Diminished breath sounds on side
Loss of lung markings on CXR
o Endotraceal Suction after whole body is delivered (not intrapartum or after head only
according to ACOG and AAP)
Apnea of Prematurity
o Respiratory pause > 20s
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
CF
Air remains trapped in meconium giving it a soap bubble appearance on XR
Hypoglycemia
o Glc <40
o Can be from excess insulin
Infants of diabetic mothers
Transient hypoglycemia
Nesidioblastosis
Islet Cell Hyperplasia
Persistent hypoglycemia
o S/Sx
Diaphoresis, jitteriness, feeding problems, tachycardia, hypothermia, hypotonia,
seizures
o Tx
Oral feedings
IV Glc if necessary
Infants of Diabetic Mothers
o Large bc of body fat and visceromegaly
Liver, adrenals, heart
o Typically LGA, but can be SGA if mother has serious DM w/ vascular complications
causing placental insufficiency
o Complications
Hypoglycemia (typically 1st 24h), polycythemia, hypocalcemia (typically 48-
96h), hypomagnesaemia Hypertrophic Cardiomyopathy, PPHN, RDS, renal vein
thrombosis
Hypocalcemia presents w/ twitching/tremors, seizures, arrhythmias
o Tx: IV Calcium Gluconate
Malformations
Structural heart, CNS, Musculoskeletal, Hypoplastic Left Colon, Caudal
Regression Syndrome (hypoplasia of the sacrum and LE)
Polycythemia
o Hct >65%
o Causes
Erythropoietin in response to placental insufficiency, fetal hypoxia,
placental transfusion from delayed cord clamping
o Tx
Partial Exchange Transfusion
Blood is removed and then replaced w/ same volume of plasma (normal
saline)
William Martin
OC USN
2.23.2015
Choanal Atresia
o S/Sx
Trouble breathing when sleeping or eating
Improved breathing w/ crying
o Dx
Unable to pass NG tube
Lack of fogging on a cold metal instrument under the nares
o CHARGE association
Coloboma
Absence or defect of ocular tissue
o Usually the retina
o Impaired vision
Heart disease (TOF)
Atresia of the choanae
Retarded growth and development
Genital hypoplasia
Ear abnormalities (cup ears & hearing loss)
William Martin
OC USN
2.23.2015
Pulmonary
Sounds
o Stridor
Squeaky, whistlelike sound that results from turbulence between supraglottis
and trachea
Extrathoracic obstruction
Laryngomalacia
o Congenital Inspiratory Stridor
"Noisy Breathing"
Worse in supine
Relieved when standing up or prone
Exacerbated by crying/feeding
o Softening and weakness of laryngeal cartilage
Collapses the airway
o Dx
Laryngoscopy
Omgea shaped epiglottis
Collapse of the supraglottic structures w/
inspiration
Croup
Foreign body aspiration
Retropharyngeal Abscess
o Fever, drooling, dysphagia, neck pain, stridor
o Dx
CT
Vascular Rings
o Persistent Stridor
o Branch of aortic arch encircles the trachea & esophagus
o Biphasic stridor and feeding difficulties
From tracheal or esophageal enacement
o Improves w/ neck extension
o Wheezing, rhonchi, and rales due to narrowing/congestion of bronchioles
o Expiratory Wheezing
Intrathoracic obstruction
Asthma
Bronchiolitis
o Crackles or Rales
Parenchymal Disease
Pneumonia
Pulmonary edema
William Martin
OC USN
2.23.2015
o S2
Pulmonary Pressure
Tracheitis
o Bacterial
S. aureus most common cause
Hx of recent URI
Previous viral laryngotracheobronchitis (croup, inspiratory stridor)
Follows w/ acute elevation in temperature, trouble breathing, change
to biphasic stridor (expiratory & inspiratory)
Brassy cough, high fever, respiratory distress
Tx for croup (mist & racemic epinephrine) dont help
Tx
Secure airway (intubation)
IV ABx
Epiglottis
o Acute inflammation and edema
o Most common 2-7 y/o
o Causes
HIB
Blood culture will be + 90%
Unvaccinated typically
GAS ( Hemolytic), Moraxella
o Sx
Rapid upper airway obstruction
Can cause Resp Arrest
High Fever (~104)
Muffled Speech
Inspiratroy stridor
Dysphagia w/ drooling
Sitting forward in tripod position w/ neck hyper extension
o Signs
Thumbprint on lateral xray
Cherry Red epiglottis
o Tx
2nd/3rd Generation Cephalosporin
Rifampin prophylaxis for non-immunized if HIB
1st step Have sterile environment and skilled personal for
nasotrachealintubation
Croup (Laryngotracheobronchitis)
o Inflammation/Edema of Subglottic Larynx, Trachea, & Bronchi
o Types
Viral
Most common, 3m to 3y, Late Fall/Winter
Spasmodic
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Asthma
o Decreased Expiratory Flow
o Sx
Nocturnal Cough (#1), wheezing (usually expiratory, really severe if
inspiratory), dyspnea
o Asthma Triad Family Hx
Eczema (atopic), Allergic Rhinitis, and Asthma
o Classification & Tx
Mild Intermittent
<2 Daytime per week
<2 Night time per month
Dont require daily, just Albuterol (short acting -agonist)
Mild Persistent
>2 Daytime per week
<4 Night time per month
Anti Inflammatory (low dose inhaled corticosteroid) + short acting -
agonist
Moderate Persistent
Daily symptoms?
>1 night time per week
Options
o Medium-dose corticosteroids + short acting -agonist
o Low-dose corticosteroids and a long-acting -agonist
Severe persistent
Continual Sx?
High-dose inhaled steroids + as long-acting -agonists + oral steroids
o Tx
If oral thrush from inhaled steroids, rinse mouth after
If signs of impeding respiratory failure
MS, silent chest (not moving air bilaterally), hypoxemia (low pO), CO
retention (acidosis)
Intubation w/ mechanical ventilation
Bronchiolitis
o Inflammation/obstruction of the bronchioles by viral infection
o Most Common Lower Respiratory Infection of First 2y
o Nov to April (winter)
o Significant in those w/ chronic lung disease, CHD, prematurity
o Causes
RSV (most), Parainfluenza, Adenovirus, Rhinovirus, Influenza
o Sx
Initial gradual URT Sx
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
o Direct Fluorescent Ab
o Eosinophilia
Tx
o Erythromycin
Mycoplasma pneumoniae
Older children & adolescents
Widespread rales & rhonchi
o Physical exam is worse than would expect by history
CXR
o Interstitial infiltrates
Dx
o + Cold Agglutinins, IgM Mycoplasma Titer
Tx
o Erythromycin or Azithromycin
Same as Chlamydia trachomatis in Afebrile Pneumonia
ICU Patients who are Intubated or have Central Lines
Pseudomonas or Candida
VZV Pneumonia
Skin findings
Pertussis
o Whooping Cough
o Immunization @ 12m
o <6m @ risk for severe disease
o 3 Stages
Catarrhal Stage
1 to 2w
URT Sx
o Rhinitis, sneezing, cough
Paroxysmal Stage
2 to 4 w
Forceful Coughing (Paroxysms)
o Can cause vomiting
Whoop
o Inspiratory gasp @ end of cough
o Rare in young infants
Cyanosis, apnea, & choking can happen in young infants
Convalescent Phase
Weeks to Months
Recovery
o Severity/frequency of Paroxysms
o WBCs (Lymphocytosis)
o Dx
Culture on Regan Lowe or Bordet-Gengou
o Tx
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
o Tx
1st nasogastric suction to decompress the bowels
2nd intubation
Surgical Correction
Transient Tachypnea of Newborn (TTN)
o Early onset Tachypnea w/in 3h
w/ nasal flaring, grunting, retractions, cyanosis
o Relieved w/ supplemental O
o Lungs are clear to auscultation
o Risk Factors
C-section
Absence of the thoracic squeeze and hormones from labor
o Research shows more likely related to hormones than the
mechanical forces, primarily cortisol
o CXR
Temporary pulmonary edema
Perihilar Streaking in the interlobar Fissure
From excess fluid in the alveoli spilling over into the extra-alveolar
interstitium
Hyperexpansion
o Flat diaphragm
Prominent pulmonary markings
o Resolves in 2 to 3d
o Corrects easily w/ O
Neonatal Pneumonia
o More common with premature, mothers w/ intrapartum fevers, PROM
o S/SX
Respiratory Distress soon after birth, circulatory collapse, jaundice, poor
feeding, abdominal distension, tachycardia, apnea, higher calorie requirement
o CXR
Nonspecific patchy infiltrates or bilateral alveolar densities w/ air
bronchograms
Persistent Pulmonary HTN of Newborn
o Tachypnea and Severe Cyanosis
o Murmur from Tricuspid insufficiency may be heard
o CXR
Pulmonary Vasculature Markings
Meconium Aspiration
o Respiratory Distress soon after birth
o Pneumothorax/mediastinum may result
o CXR
Patchy infiltrates, Coarse Streaking, & Hyperinflation (Flattened Diaphragm,
AP Diameter)
Neonatal Respiratory Distress Syndrome (Hyaline Membrane Disease)
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Risk Factors
Prone (on belly) sleeping, soft bedding, premature, twin of someone
dying of SIDS, not breastfed
Reduced dramatically by sleeping on back
Phrenic Nerve Injury
o Cyanotic w/ S/Sx of Respiratory Distress
Grunting, retractions, tachypena
o Risk factor Macrosomia/LGA (esp. infants of diabetic mothers)
o With accompanying Erb-Duchenne Palsy (e.g. tone in arm)
o CXR may appear normal
US will reveal asymmetric diaphragmatic motion
See Saw motion
Hydrocarbon Aspiration
o Gasoline, kerosene, furniture polish
o S/Sx
Dyspnea, cyanosis, respiratory failure
o Charcoal is ineffective and emesis is contraindicated (further aspiration)
o Tx
Monitor
Symptomatic
Idiopathic Pulmonary Hemosiderosis (IPH)
o Chronic history of recurrent pulmonary insults
Fever, respiratory difficulty, wheezing, cyanosis, hemopytis (pulmonary
hemorrhage)
Occult blood from swallowed pulmonary secretions
Rapid clearing on repeat CXR
Chronic hypoxia: digital clubbing
o Hypochromic/Microcytic anemia from Iron Deficiency
o Some have hypersensitivity to cow milk (Heiner Syndrome)
o Dx
Bronchoalveolar Lavage
Hemosiderin-laden macrophages
Retropharyngeal abscesses
o Suppurative infection of lymph nodes between P. Pharyngeal Wall and Paravaterbal
Fascia
o Most common organism: S. aureus, GABHS, oral anaerobes
o S/Sx
Hx of Pharyngitis
Abrupt onset of fever and severe sore throat (difficulty swallowing)
Refusal of food, drooling, muffled voice (looks like epiglottis)
Fluctuant mass
o Dx
Bulge in the P. Pharyngeal Wall
o Tx
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Cardiology
Loud Systolic Murmur @ Apex
o Mitral Regurgitation
Venous Hum
o Harmless
o R. mid clavicle
o Loudest sitting
Disappears supine
Stills Murmur
o Harmless
o Mid L. Upper Sternal Border
o Loudest Supine
Pulmonic Systolic Murmur
o Harmless
o L. Upper Sternal Border
o Loudest when Supine
Peripheral Pulmonary Artery Stenosis
o Heard in the pulmonic area (upper L. sternal border) and radiates to the axillae and
back
o Common in newborns, benign
Endocardial Cushion Defect
o Associated w/ Down Syndrome
o Complete Atrioventricular Canal (40%)
Combined ASD & VSD
Abnormal mitral & tricuspid valves
CHF by 6w
Dyspnea w/ feeds, poor appetite, lethargy, hyperactive precordium
Systolic ejection murmur
o From flow across pulmonary valve
Single S2 from pulmonary HTN
o VSD (30%)
o Large ASD (15%)
Early on CHF, hepatomegaly, FTT
Systolic ejection murmur w/ wide fixed split S2
o Markedly enlarged heart
All four chambers enlarged
Left axis deviation
Tall P Waves (R. atrial enlargement)
Infants of Diabetic Mothers
o Most common heart defect
Asymmetric Septal Hypertrophy
Only along the LVOT
o Systemic circulation
William Martin
OC USN
2.23.2015
Weak pulses
BP
Capillary refill time
o Higher incidence of Retained Lung Fluid (TTPN)
Tachypnea w/ perihilar edema and fluid in the fissures
Congestive Heart Failure
o Secondary to Congenital HDD
From bld pulmonary flow
Large VSD/PDA, Transposition of the GA, Total Anomalous Pulmonary
Venous Connection
o Secondary to Acquired
Viral Myocarditis
High Output CHF
Severe anemia
Rapid infusion of fluid
Esp. in prematures
o S/Sx
Tachypnea, cough, wheezes/rales (Pulmonary Edema), FTT, exercise intolerance
o Tx
Cardiac Glycosides (Digoxin)
Takes a while
Loop Diuretics (Furosemide, Ethacrynic Acid)
DOC b/c of rapid onset, Sx relief, and improve respiratory distress
Inotropic (Dobutamine or Dopamine)
Severe CHF
Murmur not needing workup
o Innocent flow murmurs
Typically grade I or II midsystolic ejection murmur
Changes w/ position (louder supine, disappear standing)
Acyanotic Congenital Heart Disease
o ASD
Prone to Tachyarrhythmias, Eisenmenger's Syndrome, pulmonary infections
Most small (< 8mm) close spontaneously w/in first 2 years
Ostium Primum
Lower Portion
Down Syndrome
S/Sx
RV Impulse
Systolic Ejection Murmur
o L. Upper Sternal Border
o From Pulmonary bld flow
Wide Fixed Splitting S2
o Loss of variation splitting w/ inspiration
o Ventricular Septal Defect (VSD)
William Martin
OC USN
2.23.2015
Acyanotic
Pulmonary bld flow
Pulmonary HTN
Pulmonary Markings
Holosystoloic Murmur L. Lower Sternal Border
Size of VSD 1/ Murmur intensity (smaller VSD, louder Murmur)
o Large defects, soft murmur
Moderate to large defect
murmur (Grade I to II), CHF Sx (Weight Loss, Dyspnea), Mitral Filling
Rumble @ apex
Atrial/Ventricle enlargement
Pulmonary vascular resistance (PVR) murmur and CHF
(initially)Eventually Pulmonary HTN (irreversible) -> Eventual reversal,
Eisenmenger Syndrome
Tx
Echo
o Small close spontaneously 75%
Surgical closure
o Large
By 3-6 m
o Small to Med
By 2-6 y/o
o Patent Ductus Arteriosus (PDA)
High incidence in preterms
Associated w/ Maternal Rubella infection
Aorta to Pulmonary Artery (L R shunt)
Large
S/SX
o Apical heave
o CHF Sx
From pulmonary bld flow
Pulmonary vasculature markings on CXR
Risk for Pulmonary HTN (irreversible)
o Continuous machine like murmur
L. Upper Sternal Border
o Widened Pulse Pressure
> 30 mmHg
Brisk Pulses (accentuated) (bounding)
Tx
Surgery or Indomethacin
o Coarctation of the Aorta
Associated w/ Turner Syndrome
Also associated w/ Bicuspid Aorta
If preductal, PDA can help maintain bld flow to LE w/ collateral from the
intercostals
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
o RVH
CXR
Boot Shaped Heart
Worsening of R L Shunt (Cyanosis)
SVR
o Exercise, vasodilatation, vol. depletion
Resistance through ROVT
o Tachycardia, crying
Hypercyanotic "Tet" Spells
Crying or with feeding, sudden cyanosis & Murmur
RVOT Resistance
o Worsening of R L Shunt
Squat to compensate
Venous Return to the heart SVR R
L Shunt
Knee Chest Position to SVR and R L Shunt
Morphine Sulfate to sedate and relax pulm vessels
Facemask O
o Stimulates pulmonary vasodilatation
Tx
Maintain PDA
o PGE1
Surgical Correction
o Transposition of the Great Arteries
Most common cyanotic heart defect in first month (typically presents first 24h)
Aorta arises from RV, Pulmonic A. from LV
Adequate oxygenation only by shunting
PFO, ASD, VSD, or PDA
Cyanosis @ Birth
Single LOUD S2 (FAs Qbank said normal s1 s2, can be both)
Pulmonic Valve is Posterior, cannot hear
No murmurs typically if mixing through PFO
Murmur if mixing w/ PDA or VSD
CXR
Smaller heart (egg on a string)
o Narrow mediastinum from abnormal positioning of the
pulmonary vessels
Either anteriorly or posteriorly
pulm markings
Tx
PGE to keep PDA open (first)
Emergent balloon Atrial Septostomy
o ASD or PFO
o Tricuspid Atresia
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Dx Exam CXR
Infective Endocarditis
o 80% underlying Structural Defect
o 50% after Cardiac Surgery
o Gram + Cocci
Strep ( hemolytic [S. viridians]) & Staph
o Dx
Duke Criteria
Major
o Two + Blood Cultures
o Echo showing vegetations, abscess
Minor
o Fever, predisposing cardiac condition, echo evidence, vascular
phenomena (Janeway lesions, pulmonary infarct), immunologic
phenomena (Osler nodes, Roth spots, glomerulonephritis)
o Roth's Spots
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Abrupt standing
Nitroglycerin
o Restrictive
diastolic filling from rigid walls
Causes
Amyloidosis
Inherited infiltrative DO
o Fabry, Gaucher, Hemosiderosis, Hemochromatosis
Sx
Exercise intolerance, hepatomegaly & edema from Central Venous
Pressure (CVP)
Tx
Reduce CVP w/ diuretics
blockers and Ca2+ Channel Blockers
o Diastolic filling time
Ebsteins Anomaly
o Downward displacement of tricuspid valve into the RV (Atrialization)
o May result from maternal Li+ use during 1st trimester
Used as mood stabilizer in Bipolar Tx
o Tricuspid regurg, small RV, RVOT obstruction (from small RV)
Causes RA Vol.
Leads to cyanosis
P wave on EKG
R. Axis deviation
o Severe defect
Cyanosis, systolic murmurs, massive cardiomegaly in the newborn
o Associated w/ WPW and SVT
o S/Sx
SVT
Tx: Ablate the pathways responsible for long term Tx
Fatigue and palpitations may not present till later
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Jervell-Lange-Nielson Syndrome
o AR
o Deafness
Romano-Ward Syndrome
o AD
o No Deafness
Drugs
Phenothiazines, TCAs, Erythromycin
o S/Sx
Syncope, sudden cardiac death, arrhythmias (Ventricular Tachycardia), may be a
family history of sudden death/drowning
Hypocalcemia, hypokalemia, hypomagnesaemia
o Tx
Implantable defibrillator
Propanolol (Class II, QT)
Murmur Maneuvers
o Handgrip
SVR, CO, LV Vol.
Differentiate AS from MR
AS
MR
HCM
o Valsalva
Venous Return (Preload)
RV/LV Vol
All flow murmurs , only HCM
o Inspiration
RV Vol
Both diastolic and Systolic R. sided murmurs
L. sided murmurs
o Supine to Squatting/Standing
Venous Return (Preload), SV, Arterial Pressure
Reflex HR
R. & L. Murmurs
HCM
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
Glomerular Proteinuria
Caused by Permeability of the glomerular capillaries to LMWT
proteins (microglobulin) by the tubular epithelial cells
Most common
Tubular Proteinuria
From Reabsorption of LMWT proteins
Urinary Microglobulin
o Marker for Tubular Proteinuria
Examples
o Interstitial Nephritis, Ischemic Renal Injury (Acute Tubular
Necrosis), Nephrotoxic drugs
Glucosuria & aminoaciduria may accompany diffuse injury to the
tubular epithelial cells
o Evaluation
Repeat Protein UA, if (transient proteinuria), if + ask if orthostatic
Early Morning TP/CR and Late Afternoon TP/CR
o If Early Morning <<<<< Late Afternoon, then Orthostatic, if not
then likely Persistent Pathological Proteinuria
Glomerular Proteinuria?
Dx w/ urinary Microalbumin
Ex: glomerulonephritis, Nephrotic Syndrome
Tubular Proteinuria?
Dx w/ urinary -microglobulin
Ex: Acute Tubular Necrosis, Interstitial Nephritis
Glomerulonephritis
o Typically immune-mediated (complex formation)
o Presents w/
Some w/ acute Nephritic Syndrome
Gross Hematuria, HTN, & occasionally signs of fluid overload from renal
insufficiency
Some w/ Nephrotic Syndrome
Heavy proteinuria, hypercholestermia, edema
o Labs
UA: RBC Casts
Urinary TP/CR for Persistent Pathological Proteinuria
Urinary Microalbumin
ASO titers
Rheumatic Fever
IgA levels
IgA Nephropathy
Types of Glomerulonephritis
o Poststreptococcal Glomerulonephritis (PSGN)
8 to 14d after skin infection or pharyngitis w/ a nephritogenic strain of Group A
Hemolytic Strep (S. pyogenes)
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
S/Sx
Nonthrombocytopenic (Platelet count is normal!) palpable purpura on
the buttocks and lower extremities
Typically: Abdominal pain (Colicky), arthritis (Knees & Ankles), and
gross/microscopic hematuria, mild proteinuria
If severe proteinuria, suggestive of Glomerular inflammation
o Glomerular Involvement
RBC Casts, Hematuria, Proteinuria
Monitor w/ weekly UA during active disease and then monthly for 6m after, bc
of risk of Acute Glomerulonephritis
Most cases self limited, resolve in months
o Membranoproliferative Glomerulonephritis (MPGN)
Three forms of Glomerulonephritis w/ similar features
Lobular Mesangial Hypercellularity and thickening of GBM
S/Sx
Nephrotic or Nephritic w/ gross or microscopic hematuria
HTN
Low Serum Complement
Variable course, but most develop end stage renal disease
Tx
No definitive Tx, some respond to corticosteroids and ACEI to slow
progression
Nephrotic Syndrome
o Heavy Proteinuria ( >50 mg/kg/d), hypoalbuminemia, hypercholesterolemia, edema
o 2/3 of cases present before 5 y/o
o Three Categories
Primary NS
90% of childhood cases
o Minimal Change Disease (most common)
Podocyte Feet Fusion on EM
NS that results from other primary Glomerular diseases
IgA Nephropathy, PSGN, MPGN
NS that results from other primary Glomerular diseases
SLE and HSP
o Caused by a loss of the normal charge/size selective glomerular barrier
protein loss
Hypoalbuinemia
Plasma protein production (including lipoproteins)
o Hypercholesterolemia
Frothy Urine
o S/Sx
Most present w/ edema
Ranges from periorbital to scrotal/labial to widespread edema
Edema often follows an URI
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
o Alports Syndrome
Progressive hereditary nephritis from defective Type IV Collagen in the GBM
X-linked Dominant
S/Sx
Renal
o HTN, Hematuria, ESRD
Hearing loss
Ocular (bowing of lens into A. chamber) abnormalities
Tx
ACEI to slow disease progression
Transplant
o Multicystic Dysplastic Kidney
Most common asymptomatic renal mass of newborns in first few months
Typically unilateral Cysts w/out function
Bilateral presents like Renal Agenesis
o Incompatible w/ life
Differs from Polycystic Kidney Disease in that it retains no function
o ARPKD (autosomal recessive polycystic kidney disease)
Cortical Cysts, arising in the distal tubules and collecting ducts
S/Sx
Olighydraminos from kidney function
o lung hypoplasia
Greatly enlarged cystic kidneys
o Abdominal fullness w/ bilateral irregularly shape contour
masses
Most common cause of abdominal mass of renal origin
in the newborn
o Radial spoke pattern on imaging
Severe HTN, Cr
Liver Cirrhosis
o Caput Medusa (from portal HTN)
o Esophageal varices
Tx
Renal transplant
o ADPKD (autosomal dominant polycystic kidney disease)
Presents in adulthood (20 to 40 y/o)
S/Sx
Abdominal pain, flank masses, UTI
Gross or microscopic hematuria
HTN, renal insufficiency
Associated with Cerebral Aneurysms
Tx
Transplant
o Medullary Sponge (Cystic) Kidney
William Martin
OC USN
2.23.2015
AD
Presents later in life (Non pediatric)
May be asymptomatic, hemaruria, UTI, or Nephrolithiasis
Progresses to ESRD
Small Kidneys w/ Medullary cysts (not cortex like ARPKD)
o Nephronophthisis-Medullary Cystic Disease Complex (NPH-MCD)
Juvenile Form
AR
Leads to ESRD in childhood
Adult Form
AD
ESRD later in life
Renal Tubular Acidosis
o Kidney unable to maintain normal acid-base balance bc of defects in bicarbonate
retention or defects in the excretion of H+
o Causes
Acquired
Nephrotoxic Drugs (amphotericin)
o S/Sx
Infants/young children
FTT, vomiting, metabolic acidosis
Older Children/Adults
Recurrent calculi, muscle weakness, bone pains
Classic presentation: Hyperchloremic Metabolic Acidosis w/ a Normal serum
Anion Gap
o Types
Distal RTA (Type I)
Inability to Excrete H+
Associated w/ Nephrotic Syndrome, Amphotericin, Connective Tissue
Disorders (ex. Ehlers-Danlos )
S/Sx
o Positive Urine Anion Gap
o Vomiting, Growth Failure, Nephrocalcinosis and Nephrolithiasis
o Hypokalemia, Acidemia
Tx
o Low doses of Oral Alkali
o Potassium Citrate
Corrects K+ deficit
Safer than Bicarb Salts
Proximal RTA (Type II)
Bicarbonate Reabsorption by the proximal renal tubules
Associated w/ Intoxication of:
o heavy metals, gentamicin, acetazolamide ( bicarb secretion),
global defects in tubular reabsorption (Fanconi Syndrome)
William Martin
OC USN
2.23.2015
S/Sx
o Vomiting, Growth failure, Acidosis, Muscle Weakness
Tx
o High doses of Oral Alkali
Type IV RTA
Transient Acidosis
Hyperkalemia is the hallmark
o Secondary to Aldosterone Deficiency
o Tx
Sodium Polystyrene Sulfonate (Kayexalate)
Associated w/ renal disorders and aldosterone deficiency states
Tx
o Furosemide to lower Serum K+
o Oral Alkali
o Dx
Calculation of Urine Anion Gap
Urine Na + Urine K - Urine Cl
o Positive urine anion gap is seen in Distal Tubular RTA (Type I)
Renal Failure
o Acute Renal Failure
Abrupt in Nitrogenous excretion (sudden in GFR & tubular function)
o Types
Prerenal
In renal perfusion causes a GFR
Examples
o Dehydration, hemorrhage, CHF, septic shock
Labs
o BUN/Cr Ration > 20
o Urine SG 1.030
o Urine Osmolality > 500
o Urine Na+ < 20
o FENa < 1% in older children, <2.5% in neonates
Renal Parenchymal
Damage to:
Tubules (Acute Tubular Necrosis)
o Causes: Ischemic injuries from renal hypoperfusion
o Urinary -microglobulin
o FENa > 1% in children, > 2.5% in neonates
Damage to the Interstitium (Acute Interstitial Nephritis)
o Causes: Semisynthetic Penicillins (Ampicillin) and NSAIDS
o Urinary -microglobulin
o Eosinophilia, eosinophiluria
Post Renal
Obstructive urine flow
William Martin
OC USN
2.23.2015
Causes
o Stones, Posterior Urethral Valves
Dilation of renal collecting system on US
Vascular
Perfusion of the kidneys
Causes
o Renal Artery Embolus
Umbilical A. catheter
o Renal V. Thrombosis
Sudden onset gross hematuria w/ flank mass
incidence in infants of diabetic mothers
renal blood flow on Nuclear Renal Scan
o S/Sx
Oliguria ( Urine Output <1 ml/kg/hr) or Nonoliguria
o Tx
If volume depleted
Restore intravascular first
Then restrict total fluid intake to insensible plus output (urine , stool)
replacement
Typically restrict protein, Na, K, Phosphorus
Dialysis when conservative Tx fails
Bladder Outlet Obstruction
o Posterior Urethral Valves (males)
One of most common cause for CKD leading to ESRD
Poor or absent urinary stream (Dribbling)
Bladder dilation
o Leads to a dysfunctional detrusor muscle
o VUR
Only boys
Tx
Surgical correction
o Prune Belly Syndrome
Prune Belly Syndrome
o Absence of rectus muscles
Lax, dilated, wrinkled abdominal wall
o Bladder outlet obstruction
Dilated urinary tract
Possibility of Olighydraminos
Lung Hypoplasia
o Cryptorchidism
o Other associations: Congenital Hip Dislocation, Club Feet, & Malrotation
Renal Agenesis
o Failure of development of mesonephric duct or blastema
o Unilateral is more common than bilateral (die in perinatal)
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Imipramine
o TCA used to bladder contractions in Nocturnal Enuresis
Desmopressin
o Vasopressin (ADH) synthetic analog
o Used to treat Primary Nocturnal Enuresis
Doxazosin
o -antagonist
o Tx
Daytime enuresis
Reduces bladder outlet resistance
Gastroenterology
Protein Intolerance (Milk Protein-Induced Enterocolitis)
o Majority of cases result of Milk Protein (can be from moms consumption of milk)
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Bilious Emesis
Stop Feeds
NG tube decompression
IV Fluids
Abdominal Xray
Surgery
Contrast Enema Upper GI Series Duodenal Atresia
Ligament of Treitz on
Rectosigmoid
Microcolon the right side of
Transitional Zone
abdomen
Hirschsprung Disease
o Typically rectosigmoid colon
o Also associated w/ Down Syndrome
o Normal meconium consistency
o S/Sx
Rectal examination reveals tight anal canal may lead to explosive expulsion
Squirt Sign
Bilious or Feculent vomiting (newborns), abdominal distension, constipation
(older children)
Failure to pass meconium
Or delayed (>48 h)
o Barium Swallow
Dilated proximal bowel w/ narrow distal segment
William Martin
OC USN
2.23.2015
o Dx
Screen
Anorectal manometry
Diagnostic
Lack of ganglionic cells on punch biopsy
Duodenal Atresia
o Down Syndrome
o S/Sx
Bilious Vomiting w/in first 2 days of life
Double Bubble Sign on XR
Air w/in distended stomach and proximal duodenum
o Hx of Polyhydramnios
o Dx
Prenatal Ultrasound
o Associated with Down Syndrome
o Tx
Nasogastric decompression first
IV Fluids & ABx
Surgery
Diarrhea/Vomiting and Dehydration
o Most commonly caused by Viral Gastroenteritis
o Hyponatremic, hypovolemic, hypoosmotic, low urine sodium, low serum osmolarity
Celiac
o Presents between 6m and 2y
o Gluten is in wheat, barley, rye, & oats
o S/Sx
Fatigue, weight loss
Diarrhea, vomiting, bloating
Abdominal pain & large foul smelling stools
Dermatitis Herpetiformis
Erythematous Vesicles on extensors
o Pruritic
o Associated w/ Vitiligo and T1DM
o Malabsorption
Osteoporosis/osteomalacia
Can lead to iron deficiency anemia
o Dx
Biopsy
Short villi, deep crypts, & vacuolated epithelium w/ lymphocytes
IgA endomysial Ab & Serum Tissue Transglutaminase Ab
IgG in IgA deficient pt.
o Tx
Corticosteroids for severe diarrhea
Short Bowel
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
o Physical
Olive Mass (epigastric/RUQ)
Peristaltic Wave in abdomen after feedings
o Dx
US
Thickened and elongated pylorus
Barium Swallow
May show string sign
o Small amount of barium getting past
o Tx
Correct electrolytes/dehydration (DONT OPPERATE IF ELECTROLYTE
ABNORMALITIES)
Must correct, IV hydration + Potassium
Partial pylorectomy
Malrotation of the Gut & Midgut Volvulus
o Bilious vomiting <1m
Typically asymptomatic till Volvulus
o Midgut twists around SMA (Volvulus)
Obstruction or infarction
o Common in those w/ Heterotaxy
Organs abnormally arranged across LR axis
o Lack of fixation to the abdominal wall
Can cause peritoneal bands (Ladds Bands)
Can obstruct
o S/Sx
Bilious Vomiting & Sudden onset of Abd Pain
Distension, blood in stools
Shock as bowel ischemia progresses
Peritonitis
o Imaging
Proximal distension, with little to no gas
First CXR to rule out pneumotperitoneum (free air)
UGI study of choice
Abnormal position of ligament of Tritz & Jejunum
o Right side of abdomen
o Indicates Malrotation
Corkscrew pattern indicates volvulus
Duodenum obstruction
o Tx
Surgical emergency (Ladd Procedure)
Intussusceptions
o Peak 5 to 9m
Before age 2 typically
o Ileocolic intussusceptions most common
William Martin
OC USN
2.23.2015
Viral Gastroenteritis can also cause a lead point through inflammation of the
Peyers patches
Hematomas from HSP & Mekels can also serve as lead points
o S/Sx
Sudden crampy/colicky abd pain
Periods of Colic and then normal behavior (playing laughing) or
lethargic
Vomiting
Currant Jelly Stools (Bloody Mucus) from edema and sloughing of mucosa
Sausage shaped mass in RUQ
o Dx
US
Target Sign
o Tx
Air/Contrast enema is gold standard
Avoid hydrostatic if prolonged, perforated, or peritonitis
o Air is preferred
Coil Spring Sign
May reduce the intussusceptions (therapeutic)
General
o Abdominal Rigidity
Peritoneal Process
o Restlessness
Colicky Pain
o Constant Abdominal Pain
Suggests strangulation or torsion
o Intestinal Obstruction PE
High pitched bowel sounds, abdominal distension, tenderness, & visible
peristalsis
o Peritonitis
/absent bowel sounds
Rigidity w/ guarding
Rebound Tenderness
o Appendicitis
Pain referred to T-10 (umbilicus)
PE
Tenderness @ McBurngs
Guarding
Rebound Tenderness
WBC and neutrophils
o Acute Pancreatitis
Uncommon in children
Causes
Trauma #1, idiopathic #2, infection
William Martin
OC USN
2.23.2015
S/Sx
Pain @ periumbilicus & epigastric
o Radiates to back
Severe w/ blood along the fascial planes
o Gray Turner Sign
Bluish discoloration of the flanks
o Cullen Sign
Bluish discoloration of periumbilical
Labs
Amylase
Lipase
Abdominal US for Dx
CT for complications
Pseudocyst formation
Tx
ABx if Necrotizing
Small Pseudocyst can resolve on own, but large ones may require
Cyclic Vomiting Syndrome (CVS)
o Acute and frequent vomiting that resolves spontaneous w/ no Sx in between episodes
o FHx of migraines
o Thought to be linked to abdominal migraines
o Dx
Criteria
3 episodes in 6-month
Easily recognizable to family
Lasts 1-10d
Vomiting 4 times/hr @ peak
No Sx in between episodes
No underlying condition
o Tx
Antiemetic (ondansetron [Zofran])
If FHx of migraines: Sumatriptan
Cholecystitis
o Inflammation of the gallbladder
Most commonly w/ stones
Less commonly w/out (Acute Acalculous Cholecystitis)
o Uncommon in children unless:
CF, TPN, or Sickle Cell
o RUQ Pain w/ Guarding
o + Murphys Sign
Palpation of the RUQ upon inspiration, intense pain, inspiration ceases
o Imaging
US
Stone or thickened GB Wall
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Toxic Megacolon
Risk for Colorectal Cancer
o Tx
Sulfasalazine
Can be cured w/ total proctocolectomy, but reserved for intractable colitis
Immunosuppressive Agents & Corticosteroids
Crohn's Disease
o Any segment (mainly terminal Ileum)
Can have mouth ulcers
o Skip lesions & segmental inflammation
o Transmural inflammation
Fistulas, Crypt Abscesses, Strictures
o Malabsorption
Vit B12, Zinc, Folate, Fe2+
o Perianal disease (very common) often precedes intestinal disease
Skin Tags, abscesses, fistulas
o Extraintestinal Manifestations
Much more common than in UC
FUO, arthritis, mouth ulcers, skin manifestations (erythema nodosum), weight
loss, malaise, and growth retardation
o Anti- Saccharomyces cerevisiae Ab
o Granulomas (30%)
o Imaging
String Size
Thickened bowel folds w/ narrowing of the tract
o Tx
Metronidazole
When fistulas presents
Esp. w/ inflammation
Immunosuppresive Agents & Corticosteroids
Azathioprine, cyclosporine, tacrolimus, TNF-
GI Bleed
o Hematemesis
Coffee ground appearance
o Hematochezia
Bright red, lower GI or significant rapid upper GI
o Melena
Dark tarry, upper GI (proximal to Ligament of Treitz)
o Occult bleeding from GI
Guaiac +
False +
o Ingested iron
False -
o Large amounts of ingested Vit. C
William Martin
OC USN
2.23.2015
Upper GI Bleeding
o Swallowed maternal blood
o Endoscopy if active bleeding w/ hemodynamic changes
o Tx
Initial:
Fluid Bolus w/ IV access
Octreotide for varices
PPIs
Arteriographic embolization for serious bleeding
Vascular malformations
Lower GI Bleeding
o Necrotizing Enterocolitis (NEC)
Consider in any newborn w/ rectal bleeding, feeding intolerance, & abdominal
distension
More common in prematures & Low birth weight
Immaturity of the stomach plus exposure to bacteria from enteral feeds leads to
bowel inflammation and damage
Caused by local ischemia, dilation, and infarction of loops of bowel
S/Sx
Abdominal distension, Hematochezia (or occult blood), pneumatosis
intestinalis (air in the bowel wall, double line/train track appearance)
Blood in NG tube
Complications
Intramural air spreading to portal vein (venous portal gas)
Later on intestinal perforation
o Pneumoperitoneum
Breast feeding reduces the risk of NEC
Tx
Mild
o Decompression, electrolyte repletion, IV ABx, serial abdominal
exams checking for perforation
Severe (perforation)
o Severe if perforation (free air on lateral decubitus or under
diaphragm), fixed dilated bowel on serial X-rays, abdominal wall
cellulitis
o Surgical resection and reanastomosis (exploratory laparotomy)
Following surgery, parenteral feeds for 14d
Allows for bowel rest
o Juvenile Polyps
#1 cause beyond infancy (>5 y?)
Bleeding is painless, intermittent, & often streaky
Tx
Colonoscopy w/ polypectomy
o Allergic Colitis
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
Ursodeoxycholic Acid
Used to bile flow/ viscosity
Don't use before R/O Obstructive Jaundice
Biliary Atresia
o Progressive fibrosclerotic changes of extrahepatic bile ducts
o Presents w/in first 2m of life
o S/Sx
Jaundice, dark urine, acholic (pale) stools
Moderate TB
Direct Hyperbilirubinemia
Rapid progression w/ Bile duct obliteration & cirrhosis by 4m
Hepatomegaly, Ascites, Coagulopathy, Edema
o Some have associated Polysplenia Syndrome
Bilobed lings, abdominal Heterotaxy, & situs invertus
o Dx
First perform US
Lack of Gallbladder and Triangle Sign
Will also catch other Gall Bladder DO
Hepatobiliary Scintigraphy
Failure of tracer excretion from liver
Intraoperative cholangiogram w/ Laparotomy to examine biliary tree (gold
standard)
o Tx
Kasai Portoenterostomy
Establishes bile flow by attaching intestinal loop to porta hepatis
Success is highest if <50 days old
Cholangitis is common complication (50%)
Liver transplant for liver failure
Supportive nutrition: fat vitamins (ADEK)
Ursodeoxycholic Acid
Once flow is reestablished
Viral hepatitis
o Hepatobiliary obstruction can result from swelling
Hep A
o IgM Anti HAV, early, can persist for 6m
o IgG Anti HAV, early, lifelong immunity
Hep B
o risk of HCC from Chronic Hep B
o HbsAg
First evidence of Active disease
o HBsAb
Protection: vaccine or normal infection
o HBcAb
From infection, lifelong
William Martin
OC USN
2.23.2015
o HBeAg
Rises very early in active disease
Marker for viral replication and infectivity
Dx: Acute infection
o Graph 316
o Tx
All newborns of mothers w/ active Hep B (HbsAG, HBeAG + esp.) receive HBIG
(Hep B immune globulin) & Vaccine
Autoimmune Hepatitis
o Destructive & Progressive
o serum transaminases, hypergammaglobulinemia, auto-Ab
o Types
Type I
Antinuclear Ab (ANA) or Anti-Smooth muscle Ab
More common than Type II
Type II
Anti-Liver Kidney Microsomes?
o Females before puberty
o S/Sx
50% w/ Acute Hepatitis
Mimics viral hepatitis
50% Chronic liver disease
Mild to Moderate Jaundice
o Tx
Corticosteroids
Immunosuppressive Agents
Azathioprine
6-MP
Lead Poisoning
o Remove from environment
Esophageal atresia
o Vomiting , choking, coughs w/ first feeds
o Frothing at mouth
o May have respiratory distress, abdominal distension depending on fistula
presence/location
o Associated w/ VACTER Constellation
Vertebral anomalies, anal atresia, cardiovascular anomalies, transesophageal
fistula, renal/radial anomalies
Usually accompanied by tracheoesophageal fistula leading to
abundance of gas in GI tract
o Immediate coiling of nasogastric tube confirms
Mallory-Weiss Tear
o Lower esophageal tear from forceful retching w/ or w/out vomiting
Hematemesis
William Martin
OC USN
2.23.2015
Painless bleeding
Beckwith-Wiedmann Syndrome
o Overgrowth Syndrome w/ predisposition to neoplasms
Neoplasms
Wilms Tumor & Hepatoblastoma
o Screening w/ Abdominal US and AFP
Large-sized patients
Hemihyperplasia
Macrosomia
Macroglossia
Liver/Kidney enlargement
Hyperinsulinism
Hypoglycemia at birth
Midline abdominal defects
Omphalocele, umbilical hernia
William Martin
OC USN
2.23.2015
Infectious Disease
Age Bacterial Empiric ABx
0-1 month GBS, E. coli, Listeria Ampicillin + Gentamicin or
Cefotaxime
1-3 months GBS, Strep pneumoniae, Listeria Ampicillin + Cefotaxime (or +
Vancomycin if suspect bacterial
meningitis
3 months 3 years Strep pneumoniae, HIB, Cefotaxime (or + Vancomycin if
Neisseria meningitidis suspect bacterial meningitis)
3 years adult Strep pneumoniae, Neisseria Ceftoxamine (or + Vancomycin if
meningitidis suspect bacterial meningitis)
GBS
o S. agalactiae
Listeria
o Neonates are prone, especially those w/ T Cell defects
o Gram + Rod
o Can be maternally acquired from unpasteurized dairy, soft cheeses
Mom may just have flu-like illness
Has predilection for causing amnionitis
Brown, murky fluid
Can result abortion, stillbirth, neonatal sepsis
o Neonatal distress: Respiratory distress, temperature instability,
poor feeding, lethargy/irritability
o Severe form
Gramulomatosis Infantiseptica
Pathognomic for Listeriosis
Granuloma formation and tissue destruction
o Skin (popular or ulcerative necrosis), liver, adrenals, lymphatics,
lung, & brain
Meningitis
o Bacterial
Most common in first month of life
w/ HIB vaccine
Risk Factors
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
>5,000
o Hypoglycocchacia (Low CSF Glc)
Ratio of CSF to serum Glc < .4
o Protein
o + Gram Stain/Culture
Tx
ABx by age and the most likely pathogen
o Newborns (0-28d)
Ampicillin + Gentamicin
Or 3rd generation cephalosporin (Cefotaxime)
IV Acyclovir if suspected HSV
o Young Infants (1-3m)
Ampicillin + 3rd generation cephalosporin (Cefotaxime)
+ Vancomycin if Bacterial Meningitis is suspected (given
the resistance of pneumococccus)
o Older infants & Children (>3m)
3rd generation cephalosporin (Cefotaxime)
+ Vancomycin if Bacterial Meningitis is suspected (given
the resistance of pneumococccus)
Corticosteroids
o chance of hearing loss w/ HIB meningitis
Monitor Na+ levels to watch out for SIADH
Complications
Hearing loss (most common, 25%)
Global Brain Injury (5-10%)
SIADH, seizures, hydrocephalus, brain abscess, CN palsy
Can have developmental regression
o Ex. Forgetting how to copy shapes
o Aseptic Meningitis
Definition
Inflammation of the meniges w/ CSF lymphocytic pleocytosis
And if caused by a virus
o Normal Glc, normal to minimally protein
Causes
Viral most common
o If involves the brain also, then meningoencephalitis
o Eneteroviruses
Most common in US
Summer & Fall
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
TB
o Isoniazid, rifampin, pyrazinamide, streptomycin
o Corticosteroids
Low BP w/ normal HR may indicate trending towards sepsis
Pathogen WBC Differential Protein Glc Tests
Acute Bacterial 100-50,000 (PMN) High Low + Culture/Gram
Stain (also OP)
Partially treated 1,000-10,000 Normal to high Low normal - Culture/- Gram
bacterial Stain
Viral 10-1,000 Normal to high Normal Enteroviruses may
be in culture
TB 10-500 Very High Low to very low AFB smear and
(Lymphocytes) culture rarely +
Fungal 25-500 Normal to high Low Culture may be +
(Lymphocytes) India ink + for
Cryptococcus
Parameningeal 10-200 (polys or High Normal - Culture
focus (brain monos may
abscess) predominate)
Upper Respiratory Infections (URI)
o Simple URI (Common Cold)
Rhinovirus, parainfluenza, coronavirus, RSV
S/Sx
Low grade fever, rhinorrhea, cough, sore throat
o Resolves in 7-10d
Color of nasal discharge alone doesnt predict the presence of
concurrent sinusitis
o Purulent nasal discharge may occur early in course of URI
Persistent Sx (>10d) or fever, suspect bacterial superinfection (sinusitis,
otitis media)
o Sinusitis
Clinical Diagnosis
Persistent Sx, 10d w/out improvement
Or Severe Sx (Fever 102F, purulent nasal discharge, face pain 3d)
Or Worsening Sx 5d after initial improvement of Viral URI
Pus drainage from the meatus
Formation
Ethmoid & Maxillary: present at birth
Sphenoid: Develop between 3 to 5 y/o
Frontal: 7 to 10 y/o
William Martin
OC USN
2.23.2015
Categories
Acute, subacute, chronic (based on duration of Sx)
Complications
Cerebral Abscess
o Visualized by CT or MRI
S/Sx
Persistent fever, neurologic deficits, headache,
seizures
ICP
o From accompanying edema from
abscess
Tx
Antibiotics
o Oral Amoxicillin-Clavulanic Acid (Augmentin)
Covers the most common (S. pneumoniae &
nontypeable Haemophilus influenzae)
o Pharyngitis
Causes
Viral
o Coxsackievirus, EBV, CMV
Bacterial
o Strep pyogenes (GA hemolytic Strep [GABHS] aka Strep
Throat)
o Arcanobacterium hemolyticum, Corynebacterium diphtheria
(diphtheria)
S/Sx
Viral and GABHS overlap
Viral
o Simple URI Sx
o Can have tonsillar exudates
o EBV Pharyngitis
Enlarged posterior cervical lymph nodes, malaise, &
hepatosplenomegaly
o Coxsackievirus Pharyngitis
Painful vesicles/ulcers on P. Pharynx
Soft palate (herpangina)
Blisters on palms/soles (hand-foot-mouth disease)
William Martin
OC USN
2.23.2015
GABHS pharyngitis
o Typically school age (5-15 y/o), winter & spring
o Lack of other URI Sx (rhinorrhea, cough)
o S/Sx
Sore throat
Exudates on the tonsils, Petechiae on soft palate,
Strawberry Tongue, enlarged tender A. Cervical LN
Fever
Scarlatiniform rash (also in Scarlet fever)
Sandpaper rash
o Dx
Rapid Strep
o Tx
Amoxicillin
Erythromycin for penicillin allergic
o Complications
PSGN (ABx don't prevent) and Rheumatic Fever (ABx
prevent)
Peritonsillar Abscess
Asymmetric tonsilar bulge
o Displaces uvula to side
CT
Tx
o Drainage
o ABx for GABHS & oral anaerobes
Diphtheria
o Low-grade fever & gray, adherent tonsillar membrane
o Toxin-mediated cardiac and neurological complications
Dx
GABHS
o Culture (gold standard) and Rapid Strep Test (antigen)
Tx
EBV: corticosteroids
Diphtheria
o Oral erythromycin or penicillin
o Antitoxin
o Isolation
Acute Otitis Media (AOM)
o AOM: Acute infection of the middle ear
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
o Tx
Typically self limited, but can give Azithromycin
Viral
Reactive lymphadenitis: EBV (tender generalized lymphadenopathy),
CMV, HIV
Kawaskai
Unilateral cervical lymphadenitis
T. gondii
Mono like illness w/ cervical lymphaenopathy
o Bilateral, symmetric, tender or nontender cervical adenopathy
o S/Sx
Infected node: mobile, tender, warm, and enlarged
Overlying skin is erythematous
Systemic signs may be present
o Tx
Empiric ABx against S. pyogenes & S. aureus
First generation cephalosporin (cephalexin) or anti-staphylococcal
penicillin (nafcillin)
Parotitis
o Inflammation of the parotid salivary glands
o Causes
Mumps and other Viruses (CMV, EBV, HIV)
Bilateral
Before vaccination, mumps was #1 cause
Bacterial parotitis (acute suppurative parotitis)
Unilateral
S. pyogenes & TB
o S/Sx
Fever
Neck Swelling centered above the angle of the jaw & fever
Pus in oropharynx
Can be expressed from Stensens Duct
o Complications
Mumps: meningoencephalitis (also complication of bacterial), orchitis (most
common complications, esp. for post puberty), & epididymitis, pancreatitis
Bacterial Skin/Soft Tissue Infections
o Impetigo
Superficial skin, dermis and above
Causes
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Fever
White exudates on inflamed tonsils, pharyngitis
Strawberry tongue w/ circumoral pallor
Dx
+ Culture/Throat Swab
Tx
Goal is to prevent Rheumatic Fever
Oral Penicillin VK, IM Benzathine Penicillin, or for penicillin allergic
erythromycin or Macrolide
Complications
PSGN (ABx doesn't prevent), rheumatic fever (ABx prevent), Post Strep
Arthritis (ABx doesn't prevent)
Pediatric autoimmune neuropsychiatric disorder associated w/
streptococcal infection (PANDAS)
o Acute OCD or Tic DO after Strep Infection
o ABx prevents
o Toxic Shock Syndrome
Toxin Mediated
Fever, shock, desquamating skin rash, multiorgan dysfunction
Causes
S. aureus #1, GABHS also
Tampons
Dx: 5 of 6 probable, 6 of 6 confirmed
Fever > 101
HoTN (SBP <90)
Diffuse macular erythroderma (looks like sunburn)
Desquamation (10-14d after illness)
Multisystem Involvement
o GI, Myalgias (CPK), Hyperemia of mucous membranes
(pharyngitis, vaginits), pyuria, thrombocytopenia, CNS (MS)
- cultures other than S. aureus (CSF, blood, pharynx)
Tx
Reverse shock, ABx, IVIG
Diarrhea
o Viral
Rota and Norwalk
Rotavirus
Most common infectious cause of gastroenteritis
William Martin
OC USN
2.23.2015
o Winter Months
Incubation is 1-3d
Vomiting, watery osmotic diarrhea, dehydration
o Self limited for 4-7d
Supportive Tx
Norwalk Virus
Outbreak of gastroenteritis in all age groups
o Esp. closed populations (day care, cruise ships)
Same Sx as Rotavirus, just more prominent vomiting
o Shorter duration, 2-3d
o Evaluation
Recent ABx
C. difficile
Unusual pets (e.g. turtles)
Salmonella
ELISA
Rotavirus, Giardia lamblia, C. difficile
If WBCs absent, culture is of limited use
o Non-anion gap Hyperchloremic Metabolic Acidosis
Result of bicarb loss in stools
o Tx
Fluids
ABx for: Table
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
Toxoplasmosis
Lymphoma
Esp. B cell
o Caused by EBV
Infectious Mononucleosis
o EBV #1 cause
Toxoplasmosis, CMV, and HIV can cause a similar clinical syndrome
o S/Sx
Young children may be asymptomatic
Older children: typical S/Sx
Fever, up to 2w
Malaise & Fatigue
Pharyngitis (typically exudative, resembling GABHS)
Posterior cervical lymphadenopathy
Hepatosplenomegaly
Takes weeks to months to resolve
o Complications
Post infectious Bells Palsy
o Dx
CBC shows atypical lymphocytes
May also have neutropenia, thrombocytopenia, & LFT
Monospot (first line)
Measures heterophile Ab
Less sensitive for children <4 y/o
o Instead have EBV Ab Titers
Viral Capsid Antigen (VCA) & EB Nuclear Antigen (EBNA)
Acute infection: IgM-VCA and absent EBNA
Ab
CMV causes the majority of monospot negative mononucleosis
Tx: supportive, corticosteroids for severe pharyngitis
Complications
Neurological, CN palsy and encephalitis
Severe pharyngitis can cause obstruction
Amoxicillin-Associated Rash
o EBV infected pts. who are misdiagnosed w/ GABHS and
prescribed amoxicillin develop a diffuse pruritic maculopapular
rash 1 week after
Splenic rupture
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
Abdominal complications
o Intestinal perforation, hemorrhage, strictures, local
inflammatory mass (ameboma)
Extraintestinal amebiasis
Abscess, most commonly in the liver, although can form in brain or
lungs
o Dx
Trophozoites or cysts in stool
Serum Ab Assay
US/CT of for liver cyst
o Tx
Metronidazole plus a luminal amebicide (iodquinol or paromomycin)
Giardiasis
o Giardia lamblia
o Travelers to Russia and drinking/swimming in contaminated mountain water in the
western US, daycare
o S/Sx
May persist for 2-6w (prolonged)
Diarrhea
Voluminous, watery, & foul smelling
Bloating, flatulence, weight loss
o Dx
Cysts & trophozoites in stool
Stool ELISA
o Tx
Metronidazole (same w/ Amebiasis)
Malaria
o Plasmodium: falciparum, vivax, malariae, ovale
o S/Sx
Initial: flulike Sx, headache, anorexia, fever
Cyclical fevers: correlate w/ RBC rupture
Hemolytic anemia, splenomegaly, jaundice
o Dx
Thin and thick Giemsa peripheral smear
o Tx
Chloroquine, quinine, mefloquine, doxycycline
o Prevention
Chemoprophylaxis: chloroquine, mefloquine, doxycycline, atovaquone
Toxoplasmosis
William Martin
OC USN
2.23.2015
o T. gondii
o Congenital
Triad
Diffuse Intracranial Calcifications, chorioretinitis, hydrocephalus
jaundice, hepatomegaly,
o Transmission: cat feces, ingestion of cyst contaminated, transplacental
o S/Sx
Mononucleosis-like illness
Malaise, fever, sore throat, myalgias, lymphadenopathy
Neonatal Conjunctivitis
Age of Onset Findings Tx
Chemical First day After application of Supportive, resolves
Silver Nitrate w/in 24h
prophylaxis
Tearing w/ mild
conjunctival irritation
Gonococcal 2-5d of life Marked eyelid swelling IV or IM Ceftriaxone or
Profuse purulent Cefotaxime
discharge (topical erythromycin is
prophylaxis)
Chlamydial 5-14d of life Mild swelling of eyelid Oral Erythromycin to
Thickened, injected avoid chlamydial
conjunctivae (chemosis) pneumonia
Watery or (Only prophylaxis is
mucopurulent eye maternal screening, bc
discharge Oral Erythromycin
Blood stained eye carries risk of pyloric
discharge stenosis )
Conjunctival
pseudomembrane
Pinworm
o Nocturnal anal pruritus or vulvovaginitis in prepubertal females
o Dx
Scotch Tape Test
o Tx
Mebendazole
Toxocara
o Dirt eating children can ingest the larva from dog feces contaminated soil
o Larva penetrate intestines and migrate to lung (wheezing), liver (hepatomegaly), brain
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
Severe
Low dose corticosteroids and/or Zinc oxide
Candidiasis
o Well demarcated papules and plaques
Affects the skin folds (unlike Diaper Dermatitis)
o Can develop super imposed on diaper dermatitis
o Tx
Topical antifungal
Molluscum Contagiosum Virus
o Spread by skin to skin
o More common in people w/ HIV, atopic dermatitis, immunocompromised
o Red to pink glossy papules w/ umbilicated centers
Pruritic
Causes further self annoculation (Koebnerization)
o Results in linear aggregations of papules
Often surrounded by molluscum dermatitis
Mild eczematous eruption
o Tx
None, will reduce on own
HSV
o Herpetic Whitlow
Infection of distal finger
Painful coalescing vesicles w/ erythematous base
Tx
Analgesics and observation
o Acyclovir may shorten duration
Orbital Cellulitis
o S/Sx
Proptosis, periobrital swelling, painful eye movements, & opthalmoplegia
Fever
o Associated w/ preexisting sinusitis
o Tx
Head CT to asses degree of orbital involvement
Broad Spectrum ABx
Both anaerobic and aerobic
Bacterial Conjunctivitis
o Acutely painful and red eye w/ copious purulent discharge
No fever or impairment of extraoccular movements
Torch Infections
William Martin
OC USN
2.23.2015
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
William Martin
OC USN
2.23.2015
o Tx
IG prophylaxis for household and close contacts w/in 2w of exposure
Asplenia
o Vulnerable to
Encapsulated: Strep pneumoniae, HIB, Neisseria meningitidis
Malaria, babesiosis
Group A Strep
o Strep progenies
o Pharyngitis
Rapid Step Test
+
o Treat immediately w/ penicillin
-
o Confirm w/ culture
Kawasaki Syndrome (KS)
o Medium Sized Artery Vasculitis
o Most common in Asians < 5 y/o
o Hydrops of Gallbladder
Gallbladder becomes distended w/out stone or inflammation
Abdominal pain
Seen in:
KS, GAS, Leptospirosis, Henoch-Schonlein Purpura
o S/Sx
Strawberry Tongue
Erythema w/ prominence of papillae
Seen in
o Scarlet Fever, KS, Toxic Shock Syndrome
High Grade Fever >4d, Unilateral enlarged cervical lymph nodes (>1.5cm)
Exanthem (widespread polymorphic rash)
Eventual desquamation
Thrombocytosis (>500,00 often much higher)
o Complication
Coronary Artery Aneurysm
Can lead to an MI
o Dx
Fever > 4d, Bilateral Bulbar Conjunctivitis (non-purulent), Lesions of the
lips/oral cavity (strawberry tongue, cracked lips, pharyngeal erythema),
peripheral extremity edema/erythema (swollen red hands/feet), rash, and
cervical lymphadenopathy (unilateral cervical, > 1.5cm)
William Martin
OC USN
2.23.2015
o Tx
IVIG and High Dose ASA
Yeast in urine is seen w/ those on ABx or Immunocompromised
Rheumatic Fever
o GAS
Follows infection by 2 to 4w
o Major Criteria
Migratory Polyarthritis, erythema marginatum, sub cutaneous nodules, chorea
(hand movements, lip smacking, facial twitches), carditis
(endo/myo/pericarditis)
Erythema Marginatum: Erythematous, serpiginous (wavy margins),
macular (flat, < 1cm,) lesions w/ pale centers that aren't pruritic (itchy)
o Minor Criteria
ESR/CRP, First Degree AV Block
o ASO titers
Anti-DNase B, antistreptolysin O, antihyaluronidase
o Murmurs
Mitral Regurgitation
Pansystolic
Mitral Stenosis
Loud S1 w/ mid-diastolic rumble at the apex
Can cause atrial fibrillation from LA enlargement
o EKG
PR interval
o Tx
Infection
Penicillin
Symptoms
NSAID for the arthritis
Steroids for the carditis
Diuretics & Inotropic agents if CHF
Prophylaxis against recurrence
Daily oral Penicillin or monthly IM
o Rheumatic Fever w/out Carditis
For 5y or until 21 (whichever is longer)
o Rheumatic Fever w/ Carditis, but w/ no residual heart or
valvular disease
For 10y or until 21 (whichever is longer)
o Rheumatic Fever w/ Carditis and valvular or heart disease
William Martin
OC USN
2.23.2015
William Martin
OC USN