TOP SI 117

Pediatrics

N. Srikanchanawat
1
Developmental
Milestone
Pediatrics
Nithiwat Srikanchanawat
 1. Frog position 1. 1. 1.
2. 2 2. 8-9 2. 2. >
Newborn 3. Moro, Placing, 3. Grasping 3.
Rooting, reflex
Suckling reflex

1. 1. 1. 1. Eye regard
2. Head up midline ()
1 Mo. 3. ATNR (Fencing 2. Tight grasp 2. Social smile
position) () ()
**Placing reflex gone
(1-1 mo.)
1. Head up 45 1. 1. Vowel sound 1.
() midline () 2.
2 Mo. 2. () 2.
 1. Head up 90 1. Grasp rattle 1. Coo
2. Stepping reflex () ()
3 Mo. **Rooting reflex **Grasping
gone reflex gone

1. Hold head up 1. Hand 1. Squeal 1. Enjoy observing

2. Chest up with together 2. Laugh environment
4 Mo. arm & elbow (
support
**Suckling reflex gone )

1. Roll over 1. Palmar grasp 1. Bubble 1. Orient to voice

2. Pull to sit (
5 Mo. )
 1. Sit momentarily 1. Transfer object 1. Turn to voice 1. Stranger anxiety
(Sit w/ support) hand to hand () 2.
6 Mo. **Moro reflex & 2. ,
ATNR gone 3.
3. (semisolid)

1. Sit w/o support 1. Babbling 1. Enjoy observing
() environment
7 Mo. 2. Commando (
clawing
)

1. Clawing with 1. 1. Peck-a-boo

knee () 2. 2 ()
8 Mo.
 1. Pull to stand 1. 1. 1. Bye-bye
() 2. Imitate speech 2.
9 Mo. 2. 2. sound (,
3. dada, mama) 3. ,
(ulnar)

1. 1. Pincer grasp
**
10 Mo.

1. Stand 1. Release an 1. 1-2 meaningful 1. Come when

momentarily object on words & called
1 Yr. 2. Walk with 1 hand command ) 2.
held 2. 3.
 TOP SI 117

Growth & Development

Growth assessment
- Body weight (BW)
Age BW
NB 3.25 kg
4 mo. 6 kg
1 yr. 9 kg
2 yr. 12 kg
4 yr. 15 kg
( 0-4-1-2-4 = 3-6-9-12-15)
BW 2 NB 4 mo. (6 kg)
- BW
.+
Age < 1 yr. (3-12 mo.) BW = ( < 1 yr. BW 0.5 kg/mo.)

Age 1-6 yr. BW = 2(yr.)+8 ( 1-6 yr. BW 2 kg/yr.)
()
1 = 3 NB = 9 kg
2 = 4 NB = 12 kg
2 kg
.
Age 7-12 yr. BW = ( 7-12 yr. BW 3.5 kg/yr.)

- Length/Height (Ht.)
Age Ht.
NB 50 cm
6 mo. 65 cm
1 yr. 75 cm
2-12 yr. 6(yr.)+77
Ht. 2 NB 4 yr. (100 cm; 6(4)+77 = 101 cm)
01 yr. Ht. 25 cm
12 yr. Ht 12.5 cm
2-12 yr. Ht 6 cm/yr. ( 6-7 cm/yr. 5-6 cm/yr.)
- Head circumference (HC) occiput () glabella;
Age HC
35 cm
NB
(36 2 cm)
4 mo. 40 cm
10 mo. 45 cm
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4 yr. 50 cm
10 yr. 55 cm
(4-10-4-10 5 cm; 3-9-3-9)
- Fontanelles
1. Posterior fontanelle (PF) 3 , ; 1 mo.
2. Anterior fontanelle (AF) 4 , 4-6 cm; 1 yr.
( PF AF, )
- Chest circumference (CC)
NB: CC < HC (CC NB = 33 cm; CC = HC-2)
Age -1 yr.: CC = HC ()
Age > 1 yr: CC > HC ()
- Upper:Lower segment (U:L) ratio : lower segment fix pubic symphysis
lower segment upper segment Ht. - lower segment
U:L ratio = 0.9-1;
Age U:L ratio
NB 1.7
6 mo. 1.6
1 yr. 1.5
2 yr. 1.4
3 yr. 1.3
4 yr. 1.25
5 yr. 1.2
10 yr. 1
- Arm span ( 2 ) ~ Height 5 cm
Marfan syndrome arm span
- Onset of puberty
Boy: puberty 9-14 yr.; 1st sign Testicular enlargement
Girl: puberty 8-13 yr. (); 1st sign Breast enlargement
- Tanner stage of Breast
Stage 1
Stage 2 Breast bud
Stage 3 1
Stage 4 2 (areola )
Stage 5 Nipple protrude ( 1 stage 3)
- breast menses ~ 3
- Total pubertal growth puberty
 TOP SI 117

Boy: 25-30 cm
Girl: 20-25 cm
- Midparental height Ht. ( 100% factor)
(Ht .+)+13
Boy: 7cm
2
Ht . 13
Girl: 7cm
2
- Ht. < P3 & = Short stature
(, , ) Ht. < P3 ( genetic ) = Familial short stature
delayed puberty, bone age = chronological age
- rate curve P3, delayed puberty, bone age = height age (
chronological age) = Constitutional delay (rate curve delay )
- Ht. > P97 & = Tall stature
- Weight for height (%W/H)
Failure to thrive (FTT)
- FTT < 5 yr.; Dx
1. BW < P3 ( BW ; Ht. normal < P3 )
2. Growth curve 2 (major percentile lines)
- FTT BW Ht. Ht. = chronic
- FTT
1. Organic cause
1) GI: Cleft lip / Cleft palate, Pyloric stenosis, GERD, Cow milk allergy, Hepatitis, Cirrhosis, Diarrhea
2) Renal: UTI, RTA, Renal failure
3) CVS: CHD
4) RS: OSA
5) Brain: CP, MR
6) Endocrine: GH deficiency, Hypothyroid, Cushing syndrome, Hypopituitarism, Delayed puberty
( Hx Menstruation, Tanner stage), Polyuria, Polydipsia
7) Genetic: DS, Turner syndrome, Skeletal dysplasia
2. Non-organic cause
1) Normal variation
2) Inadequate calories ( Hx , solid
food infant 6-7 mo.)
3) Psychosocial (environmental) factor < 3yr.
- Investigation
1. CBC Anemia, Malnutrition
2. ESR Chronic inflammation / infection
3. Electrolyte Metabolic acidosis / alkalosis
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4. BUN/Cr Renal function

5. Stool for parasite
6. Ca, PO4, ALP Metabolic bone disease
7. FPG DM
8. TFT Hypothyroid
9. AST, ALT Chronic liver disease
10. Albumin Chronic liver disease, Malnutrition
11. Tuberculin skin test TB
12. Anti-HIV
13. Developmental test brain / environment
- Management
1. Specific treatment
- cause / cause
( chronic disease; hormone deficiency e.g. GH )
2. General management
- Diet 5
- Supplement Vitamin D, Ca, P, Fe, Mg, Zn
- Behavioral modification
- Goal: Catch up growth
-
- feed 6
6 mo. 1, 4-5
9 mo. 2, 4
12 mo. 3, 3
- , ,
- Development, Development
- Refer
FTT
1. Growth velocity 2-3 mo. ( Endocrine disorder)
2. Obvious syndromic feature
3. Severe malnutrition
4. Suspected child abuse / neglected child
Developmental milestone
- 4 Gross motor, Fine motor, Language, Personal-social ()
- development preterm Corrected age GA 40 wk.
development
- Delayed development 4 = Global delayed development (GDD)
 TOP SI 117

- Development ---
- Frog position NB
- Head up 1
- Head up 45 2
- Head up 90 3
- Hold head up 4
- Pull to sit, Roll over 5
- Sit w/ support 6
- Sit w/o support, 7
- 8
- Pull to stand (), 9
- 10
- 1 1
- 15
- 1
- 2
- 3
- 6
- Development -
- 15
- 1 1
- 2
- , 3
- 4
- Development
- 2 (jump) 2
- (hop) 4
- (skip), 5
- Development
- Grasping reflex NB
- Tight grasp 1
- Loose grasp 2
- Grasp rattle, Grasping reflex gone 3
- Hand together 4
- Palmar grasp 5
- Transfer object hand to hand 6
- 2 , 8
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- 9
- Pincer grasp 10
- Release object on demand, 12
- 2 , , 15
- 3 , 1
- 6 2
- 8 3
- 4
- 6
- Development
- 1
- 2
- 3
- , 4
- , 5
- 6
- Development
- 8
- 1
- (parallel play) 2
- 3
- 4
- 6
- Development
- (babble), jargon 9
- (single word) 1
(Delayed speech Dx 15 mo. babble, 2 yr. single word)
- 1
- 2-3 2
- , , 4
- 5
- , , 6
- Development
- 6
- 9
- 2
- 3
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Neonatology
General considerations in neonatology
- 7 ( round NB )
1. Temperature keep core T ( rectum) 37C0.2 (36.8-37.2C)
(: thermometer 3 cm (term), 2.5 cm (preterm) 3 min)
LR: T 25-26C
Nursery: T 26-28C
2. Respiration keep RR 40-60/min, airway , Sao2 92-95% ( 95%
O2 toxicity e.g. ROP esp. Preterm, MAS keep Sao2 > 98%)
2 hr. RR > 60/min
3. Nutrition / IV fluid
4. Infection
5. Specific treatment (e.g. Early neonatal sepsis ATB: Ampicillin + Gentamicin 10-14 d)
6. Bonding ,
7. Development
- Neonatal period = D.0-28 (4 wk.);
1. Early = D.0-7 (Wk.1)
2. Late = D.8-28 (Wk.2-4)
- Term: GA 37 wk. ( 40 wk.)
Preterm: GA < 37 wk.
Postterm: GA 42 wk.
- DOL = 1 (DOL = day of life)
- Apgar score 1, 5 min
Score 0 1 2
Appearance (Color) All blue, pale Pink body, Blue extremities All pink
Pulse (HR) Absent < 100/min > 100/min
Grimace (Response to nasal None Grimace Sneeze, Cough
catheter / tactile stimulation)
Activity (Muscle tone) Limp Some flexion of extremities Active
Respiration Absent Irregular, slow Good, crying
At 5 min: Score 7-10 Normal; Score 4-6 Intermediate; Score 3 Low
Intermediate & Low (At 5 min: Score < 7) = Perinatal depression 5 min
score 7
Perinatal depression NPO organ (
vital organ ) Bowel ischemia infection NEC
- Severe asphyxia 4
 TOP SI 117

1. Low Apgar ( 3) 5 min

2. Fetal acidosis (pH < 7 cord blood gas)
3. HIE
4. Multiorgan involvement
- PPV Apgar PPV HR (e.g.
Pethidine Naloxone)
- Birth weight
Weight
1. Normal birth weight: 2,500-3,500 g
1. Low birth weight (LBW): < 2,500 g
2. Very low birth weight (VLBW): < 1,500 g
3. Extremely low birth weight (ELBW): < 1,000 g
4. Macrosomia: 3,500 g
Percentile
1. Appropriate for GA (AGA): P10-P90
2. Small for GA (SGA): < P10 Symmetrical, Asymmetrical (Disproportionate)
3. Large for GA (LGA): > P90
- Temperature control 3
1. Wrapping
2. Radiant warmer () :

3. Infant incubator ()
- = 20% BSA heat loss
- Measurement: HC, Length, BW Ballards score ( I/C GA )
- Cold care: topical antiseptic (e.g. Triple dye)
- Routine medication
1. 1% AgNO3 ( Ophthalmia neonatorum)
2. Vit. K1 (Phytonadione) 1 mg IM ( Hemorrhagic disease of the newborn)
3. BCG 0.1 cc ID, HBV 0.5 cc IM (w/in 12 hr.)
- Routine screening
1. PKU: Phenylalanine level
2. Congenital hypothyroidism: TSH level D.3-5
- Ballards score: GA ; I/C 5
1. Preterm
2. Postterm
3. LBW SGA & LGA Postterm
4. UCD
 TOP SI 117

5. No ANC
2 Neuromuscular Physical score 2
Physical x2

Square window: mature (

)
- SBP birth weight
3 kg keep SBP 60 mmHg
2 kg keep SBP 55 mmHg
1 kg keep SBP 45 mmHg
- HR 120-160/min
Tachycardia: HR > 180/min
Bradycardia: HR < 100/min
- RR 40-60/min; RR 1 min NB irregular = Periodic
breathing ( ) 5 sec
- Sao2 keep > 95% (term), 88-92% (preterm)
- O2 preterm hyperoxia preterm (e.g. ROP, BPD)
 TOP SI 117

keep Sao2 99-100% preterm distress PPHN (hypoxia

pulmonary vasoconstriction PPHN)
- Feeding Start breastfeeding (BF) as soon as possible ( C/I feeding)
Term: BM/BF/SI 20-30 cc/kg/d x D. D.7; 8 feeds
: D.1 20-30 cc/kg/d x 8 feeds step 10 cc D.7
e.g. 3,500 g D.1 30 cc/kg = 105 cc = 13 cc x 8 feeds (TV = 30 cc/kg)
D.2 13+10 = 23 cc x 8 feeds (TV = 52 cc/kg); D. 10 cc x 8 feeds D.7
Preterm: BM/BF/SI 10-15 cc/kg/d x D. D.14; 8 feeds
: D.1 10-15 cc/kg/d x 8 feeds step 5 cc D.14
(BM = Breast milk ( ), BF = Breastfeeding (), SI = Stock I
infant formula 1 yr.)
- Physiologic weight loss NB
- Term weight loss 10%, onset D.1, ~ D.3
- Physiologic polyuria (water loss)
- weight Birth weight gain weight weight
- gain weight birth weight 1 wk. (Term), 2 wk. (Preterm)
- weight gain Preterm weight ideal weight
Full feed , step
- Calories
BM/BF/SI 1 oz. (30 cc) 20 kcal
PF (Premature formula)/HMF (Human milk fortifier; 1 50 cc) 1 oz. 24 kcal
- infant formula (e.g. Stock I) 1 yr. PF preterm BW <
1,800 g ( preterm , BW PF infant formula ; preterm
calories , lipid MCT)
- OG tube: feed OG tube 2
1. Maturation : co-ordination & feed OG tube
( sucking reflex , swallowing GA 32-34 wk. GA
maturation )
2. Clinical : Respiratory distress ; RR > 60/min feed OG tube
- GA GA GA 32 wk. ( swallowing)
e.g. GA 28 wk. 32 wk. (Postconceptional age (PCA) = GA + Postnatal age = 28+4
wk.) 4 wk.
- IV fluid: / Starvation / Hypoglycemia
- Total volume (TV) (cc/kg/d)
Term: D.1-6 TV = 65, 65, 80, 100, 120, 150 cc/kg/d
Preterm: D.1-8 TV = 60, 65, 80, 80, 100, 120, 120, 150 cc/kg/d

 TOP SI 117

Day 1 2 3 4 5 6 7 8
Term 65 100 120 150
65 80 150
Preterm 60 80 100 120
(D.1 65 60; D.2-3 ; D.4-7 1 step)
D.1-2 10%D/W ( Electrolyte shock load NSS
isotonic )
(10%D/W 100 cc glucose 10 g 40 kcal)
> D.3 10%D/N/5
- + IV fluid volume , TV TV
IV fluid
volume (20-30 cc/kg/d term) D.3
volume TV
Strength Rate
- Glucose production rate (GPR) =
6 BW
(Strength %D, Rate cc/hr., BW kg)
Term: GPR = 4-6 ( / IV GPR 4 F/U DTX
Hypoglycemia GPR 15)
Preterm: GPR = 6-8
- GPR 2 () Strength & Rate
Strength %D peripheral line 12.5% central line
(UVC)
Rate volume limit
- order NB
One day Continue
Hct, DTX, BS Routine newborn care
BM/SI (20 kcal/oz) __ cc x 8 feeds (TV = __ cc/kg) Record V/S q 4 hr.
- Monitor SBP 60 mmHg ( BW )
- T 36.8-37.2C
- RR 40-60/min
- HR 120-160/min
- Sao2 > 95%
Record BW OD
Record Lt, HC once a week
- Primitive reflex incomplete myelination
Demyelination Persistent primitive reflex ( Myelination
Primitive reflex)
- scalp: Cephalhematoma, Subgaleal hematoma, Caput succedaneum
1. Cephalhematoma
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- suture
- Soft, fluctuation, (subperiosteal hemorrhage)
- ! introduce infection , counseling , F/U
2. Subgaleal (Subaponeurotic) hematoma
- suture
- Soft, fluctuation, aponeurosis ( & space
)
- 90% vacuum
- Head trauma (ICH, Skull Fx) 40%
- 12-72 hr. , Hemorrhagic shock
3. Caput succedaneum
- suture
- Tense, fluid
- pressure
- skull bone = Molding
- Cephalhematoma, Subgaleal hematoma anemia, Hyperbilirubinemia
Phototherapy / Exchange transfusion
- Molding Craniosynostosis
Molding bone
Craniosynostosis bone
- NB 95% meconium 1 d, 99% meconium 2 d
- NB 95% void 1 d, 99% void 2 d
Normal findings in the newborn
- NB
1. Vernix caseosa = heat loss;
source of infection
2. Erythema toxicum neonatorum (ETN) = erythematous macule () , , ,
()
- , hypersensitivity reaction
- ~ D.10, 5 d, 2 wk.
- confirm ETN vesicle vesicle Wrights stain
Eosinophil; G/S negative
3. Mongolian spot = hip/coccyx; ~ 4 yr.
4. Desquamation (Skin peeling) = skin term D.1-2 , ;
2-3 d
Preterm: Desquamation , GA
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Desquamation Postterm dysmaturity asphyxia

uterus
5. Mottling (Cutis marmorata) = skin (); vasomotor center
capillary & venule dilate constrict ( )
6. Acrocyanosis (Peripheral cyanosis) = ; peripheral circulation
24 hr.
7. Harlequin sign = skin /
; circulation 4 d. , 3 wk.
8. Sebaceous gland hyperplasia = ; , ,
9. Milia (Epidermal inclusion cyst) = (papule) ; sebaceous gland
obstruction; , , ( sebaceous gland hyperplasia); 40%
term; 1-2 wk.
10. Epstein pearl = junction hard & soft palate hard palate 2
1 5-6
11. Bohn nodule = /
12. Miliaria = keratin sweat gland; ;
3
1) Miliaria crystallina (Sudamina rash) = vesicle 1-2 mm,
2) Miliaria rubra = NB
3) Miliaria pustulosa = ( neutrophil, bacteria)
- CVS: NB TR (tricuspid regurgitation) physiologic , 48 hr.
- Liver: NB 2-2.5 cm below RCM, soft, sharp edge
- Spleen: NB 1 cm below LCM
- Penis: NB = 2 cm; Penis < 2 cm = Micropenis
- WBC NB esp. D.1 30,000/mm3
Infant incubator
- Infant incubator ()
1. T air > T 2C (e.g. Preterm incubator try wean)
2. Respiratory distress observe signs ( tachypnea, retraction)
3. Infection ( infection)
- incubator = Sniff position
- T incubator 2 modes
1. Air servocontrol mode
- NTE (neutral thermal environment) T air
(NTE T basal metabolism; Age & BW)
2. Skin servocontrol mode ( skin probe)
- T air T skin probe
 TOP SI 117

- skin probe skin (e.g.

, )
T
probe / / T heat T skin
probe core T T
( skin mode check probe
error )
- T skin core T T range 36.2-36.8C ( 36.5C)
- core T T ; 0.1C
- Skin mode T T instability Skin mode
T Air mode ( T NTE) T T
T core T wean
Neonatal hypoglycemia
- Hypoglycemia DTX NB Hypoglycemia Blood sugar < 40 mg/dl
- DTX 10 mg/dl DTX < 50 mg/dl Glucose (NaF)
Lab. ; Hypoglycemia 10%D/W 2 cc/kg IV push
NB Physiologic hypoglycemia 2-3 hr. ( cord)
Start BF as soon as possible
- Maternal DM ( = Infant of diabetic mother) Hyperinsulinism (
umbilical cord cord
Physiologic hypoglycemia 2-3 hr. ( 30-60 min)
Maternal DM Hyperinsulinism Hypoglycemia )
- Hypoglycemia SGA Storage
Preterm Prematurity (Counter-regulatory hormones, Gluconeogenesis )
- ketone NB ( fat )
- hyperglycemia e.g. PHHI, Hypopituitarism, Beckwith-Wiedemann syndrome (BWS)
BWS spot Dx 5
1. Macroglossia
2. Macrosomia
3. Neonatal hypoglycemia
4. Midline abdominal defect (e.g. Omphalocele, Umbilical hernia, Diastasis recti)
(Diastasis recti Rectus m. weak
Increased intra-abdominal P weak )
5. Ear creases or ear pits
- Management
1. Asymptomatic: Early feeding 10%D/W IV
DTX < 25 mg/dl Minibolus (10%D/W 2 cc/kg IV push)
 TOP SI 117

2. Symptomatic: 10%D/W 2 cc/kg IV push = Minibolus F/U DTX 30 min, 10%D/W IV, keep GPR
4-6; F/U DTX GPR 2 q 30 min ( F/U DTX ), F/U DTX
GPR hypoglycemia; DTX , GPR 1 ( 1-2
)
- GPR 12 hypoglycemia ( LGA )
Hydrocortisone
- Persistent hypoglycemia 7 d
Neonatal polycythemia
- Polycythemia NB = Hct 65%
- Dx Polycythemia Partial exchange ( UVC NSS
dilute )
1. Hct 65% + S&S of Hyperviscosity syndrome ( active (lethargy), cyanosis, respiratory
distress, plethora, seizure, feeding problems, signs of poor tissue perfusion, etc.)
2. Hct 70%
- Hct Partial exchange 50-55%
- Volume Partial exchange = (Hct Hct ) x Blood volume; cycle 3-5 cc/kg,
15-30 min ( Hypovolemia, BP drop )
(Blood volume = 0.8 x BW)
e.g. 2 kg, Hct = 70% Partial exchange = (70-50) x 0.8 x 2 = 32 cc, cycle 3-
5 cc/kg = 6-10 cc/cycle 4-5 cycles
Neonatal hyperbilirubinemia
- Neonatal jaundice
1. Physiologic jaundice 24 hr. (~ D.2-3) liver
2. Pathologic jaundice 24 hr. , , ,
: MB rate > 5 /d > 0.5 /hr
: onset 24 hr.
: > 7 d (term), > 14 d (preterm)
- MB : ()
5
10
15
20
NB indirect () direct ();
direct: TB DB 20%
- Hct, MB; plot MB graph zone : LR/LI/HI/HR, on Phototherapy /
Exchange transfusion
(LR = low risk, LI = low intermediate, HI = high intermediate, HR = high risk)
 TOP SI 117

MB LR/LI 2 off F/U

on Phototherapy F/U MB on Phototherapy 2 off
Phototherapy
- Phototherapy
- special blue light (Toshiba deep blue) MB
- ()
- ,
- 2,400 hr.
- F/U Hct, MB MB , MB rate 0.2 /hr.
- Intensive phototherapy < 24 hr. MB 1-2 mg/dl 4-6 hr.
- off Phototherapy Jaundice rebound 30%
- Double phototherapy =
1. on Phototherapy MB Exchange try Double
phototherapy
2. Exchange Double phototherapy Exchange transfusion
( UVC)
- Exchange transfusion
- UVC PRC Gr. O (2 ) + FFP Gr. AB (1 )
- Exchange 2 Blood volume = 2 x (0.8 x BW)
- cycle 2-3 cc/kg 1 hr.
- Complications: Hypovolemic shock, Volume overload, Hypoglycemia ( RBC
), Infection, Blood transfusion reaction
- UAC / UVC
UAC: (cm) = (3 x BW) + 9
3BW +9
UVC: (cm) = + 1 ( UAC 2 1)
2
CXR: UVC diaphragm UVC ductus venosus IVC
Neonatal respiratory distress
- Signs of respiratory distress
1. Tachypnea (RR 60/min) Minute ventilation; sign
2. Retraction subcostal, intercostal, substernal ( accessory m. )
3. Nasal flaring ( accessory m. )
4. Grunting (), Moaning ()
Grunting vocal cord
vocal cord
5. Cyanosis 1.-4. compensate
- Signs of hypoxia 3
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1. Tone ()
2. HR ()
3. RR ()
vigorous
- Nasal obstruction: test nasal airflow
obstruction respiratory distress
turn Obstructive apnea
Nasal obstruction: NSS Iliadin (Oxymetazoline) q 8 hr.
Iliadin decongestant Imidazoline derivative 3
Rebound congestion & Rhinitis medicamentosa 3 1 )
- Choanal atresia Obligate nose breather =
Choanal atresia
- Hyperoxia test cyanosis cardiac cause (Cyanotic heart disease)
( non-cyanotic Hyperoxia test )
- C:T ratio NB = 0.55 ( 1 yr. 0.5 adult)
- Cause of respiratory distress NB 4
1. Postnatal adaptation
2. Transient tachypnea of the newborn (TTN)
3. Meconium aspiration syndrome (MAS)
4. Respiratory distress syndrome (RDS, Hyaline membrane disease, HMD)
Postnatal adaptation
- Respiratory distress Postnatal adaptation 2 hr. ( LR ) ,

Transient tachypnea of the newborn (TTN)
- TTN delayed absorption pulmonary fluid ( fluid lung ) respiratory
distress 2 hr.
- Risk factor 4
1. C/S (esp. Elective C/S labor pain)
2. Prolonged labor
3. Maternal DM
4. Maternal Asthma
- PE: Breath sounds
- CXR: Sunburst appearance ( perihilar 2 ), Hyperaeration, fluid
Minor fissure, air bronchogram (esp. ), F/U film absorb fluid
pattern clear , ( lymphatic system)
- Management: Supportive, absorb fluid ; 3-5 d
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- keep Sao2 98% Sao2 O2 Sao2 = 100% predict Pao2

Pao2 vary range
Meconium aspiration syndrome (MAS)
- MAS meconium Airway obstruction, Surfactant inactivation, Chemical
pneumonitis; respiratory distress 4 hr., severity
- PE: Increased AP diameter, Crepitation PPHN
Increased AP diameter NB
1. MAS
2. Pneumothorax
3. CDH
4. LGA ( fat chest )
- meconium Meconium-stained AF (MSAF) Fetal hypoxia
- Risk factor 4
1. Postterm
2. IUGR
3. UPI
4. Stress ( e.g. Infection, Anemia)
- CXR: Alveolar infiltration, Irregular patchy infiltration ( chemical pneumonitis), Atelectasis
( airway obstruction), air trapping area meconium
Pneumothorax (Anterior / Medial / Basal) /
Pneumomediastinum / Pneumopericardium
Patchy infiltration
Pneumothorax / Pneumomediastinum / Pneumopericardium / Pneumoperitoneum / Pulmonary interstitial
emphysema (PIE) Air leak syndrome
Spontaneous pneumothorax NB ; : Resistance lung
part NB air part P
Pneumothorax area (Anterior / Medial / Basal)
- MAS criteria 4
1. Hx of MSAF
2. Tracheal suction with meconium content
3. Clinical feature of respiratory distress
4. CXR: Patchy infiltration, Emphysema from air trapping, Hyperaeration
- Management
1. MSAF + Fetal distress suction ( tube meconium
aspirator) MAS
2. Thick meconium PHT D.2 (, desat.) Thick meconium
observe 24 hr.
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2. MAS Supportive, ATB ( meconium sterile media

bacteria infection )
Respiratory distress syndrome (RDS)
- RDS Preterm ; surfactant
atelectasis, gas exchange respiratory distress 4-6
hr.
surfactant GA 37 wk. Pneumocyte type II, process
labor Catecholamine surge surfactant
- tachypnea, retraction, nasal flaring, grunting, cyanosis apnea respiratory failure;
D.2-3
- Risk factor
1. Preterm (esp. GA < 34 wk. Dexa. 4 doses)
2. Maternal DM (delayed lung maturity)
3. Perinatal asphyxia ( surfactant)
4. Pneumonitis ( surfactant)
5. Twin B
- CXR: Ground glass appearance ( severe), Reticulogranular pattern, Air bronchogram, Hypoaeration
( TTN lung volume alveoli collapsed)
- Management: Supportive, surfactant ~ D.4
Neonatal apnea
- Apnea Dx
1. Respiratory pause > 20 sec
2. Respiratory pause ( sec ) + Bradycardia (HR drop) / Central cyanosis (Sao2 drop, )
( NB Periodic breathing Respiratory pause 5 sec, HR & Sao2
Bradycardia / Central cyanosis; Apnea DDx Periodic breathing & Subtle seizure)
- Apnea 3
1. Central apnea RC (Respiratory center) immature IVH ( Preterm) RC
pathology chest movement, Sao2
2. Obstructive apnea obstruction airflow (e.g. Choanal atresia) chest movement,
Sao2
3. Mixed pattern
- Cause of apnea
1. Preterm Apnea of prematurity (AOP) D.2-3 ( D.1) Central
apnea / Obstructive apnea / Mixed (most common Mixed)
2. RC pathology, infection (e.g. meningitis)
3. Airway obstruction ( respiratory distress )
 TOP SI 117

4. Metabolic: Hypoglycemia, HypoCa2+, HyperMg2+

HyperMg2+ NB Hx Maternal preeclampsia MgSO4
HypoNa+, HyperNa+ apnea NB ( Electrolyte )
4. Drug: Pethidine ( LR)
5. Sepsis
6. GERD
7. PDA Preterm ()
- apnea = Tactile stimulation
Neonatal seizure
- Neonatal seizure 5
1. Subtle ( - b) ;
/- , , /
, , , , (
)
(Subtle seizure )
2. Multifocal clonic / (),
Cerebrum (diffuse) e.g. HIE
3. Focal clonic / / , Cerebral vessel e.g. Cerebral
infarction, ICH
4. Tonic , ( Decerebrate &
Opisthotonos ), Frontal lobe
5. Myoclonic () - Jerking movement
Myoclonic seizure ; Infantile spasm (prognosis )
Myoclonic seizure + Alteration of consciousness Inborn errors of metabolism
- Seizure VS Jitteriness
Seizure
Jitteriness
Jitteriness = / response , , ; Hypoxia, Maternal drug
abuse, Hypoglycemia, HypoCa2+
- DDx (Cause): HIE, ICH, IVH, Inborn errors of metabolism
- e.g. Chorioamnionitis ( CNS infection ), Dystocia
( Brain injury / hematoma)
- Management ( emergency)
1. RR, V/S: / on ETT
2. DTX, Ca2+, Mg2+ ( Hypoglycemia, HypoCa2+, HypoMg2+)
Hypoglycemia 10%D/W 2 cc/kg IV push (Minibolus) 10%D/W IV drip, keep DTX 70-
120 mg/dl
 TOP SI 117

HypoCa2+ 5% Ca gluconate 4 cc/kg IV , monitor HR Bradycardia / Arrhythmia

( 10% Ca gluconate Sterile water 1:1)
HypoMg2+ 50% MgSO4 0.2 cc/kg IM
3. AED
1) Phenobarbital (PNB) 1st line AED NB
- Loading dose: 20 mg/kg IV drip in 10-15 min, add 5 mg/kg (Max
40 mg/kg); observe apnea
( .. NICU NICU tube, ventilate 40 mg/kg
; NICU 40 mg/kg )
- Maintenance dose: 3-4 MKD
- PNB 1 ( Valium ) Valium
albumin IB free
form BBB Kernicterus ( permanent brain damage)
2) Dilantin (Phenytoin) 2nd line
- Loading dose: 15-20 mg/kg IV 30 min; observe HR
Bradycardia, Arrhythmia, Hypotension
- Maintenance dose: 4-8 MKD
- off AED off backward ( off Dilantin PNB 1 )
Neonatal sepsis
- Neonatal sepsis unspecific T instability, Tachycardia, Tachypnea, Abdominal distension,
, Poor tissue perfusion (Capillary refill > 2 sec), Seizure ( meningitis), etc.
- Risk factor: Preterm, LBW, Low Apgar, Maternal prolonged PROM / Chorioamnionitis, AF
- Temperature instability
Fever: T > 37.5C
Hypothermia: T < 36.5C
- Neonatal sepsis CBC & + Ballards score
- WBC < 5,000/mm3 (Leukopenia) & I:T ratio > 0.2 Neonatal sepsis
- I:T ratio (I = immature neutrophil, T = total neutrophil) Shift to the left (immature neutrophil
) > 0.2 (20%) Bacterial infection
- Neonatal sepsis onset 2
1. Early-onset (< D.3 < D.7 )
- birth passage e.g. GBS, E. coli, Listeria
- ATB: Ampicillin + Gentamicin 10-14 d ( H/C sensitivity)
- Meningitis
Gram +ve ATB 2 wk.
Gram ve ATB 3 wk. CSF profile
2. Late-onset
 TOP SI 117

- e.g. Klepsiella (common), CNS (Coagulase-negative Staph. e.g. S.

epidermidis; pathogen contamination ), A. baumannii, Enterococci,
Enterobacter, Pseudomonas ( Ventilator)
- UVC line sepsis Staph. ( MRSA ), TPN
phlebitis
- ATB: Claforan (Cefotaxime) + Amikin (Amikacin)
Pseudomonas Cefotaxime Ceftazidime ( Fortum + Amikin)
MRSA UVC Vancomycin ( Claforan + Vanco. Amikin +
Vanco. )
TORCH infection
- TORCH Toxoplasma, Others, Rubella, CMV, Herpes
- CT Brain:
Toxoplasma Diffuse calcification
CMV Periventricular calcification
Herpes Temporal calcification
Herpes infection
- Herpes Vaginal route Herpes ( I/C C/S)
ROM 4 hr. C/S ascending infection
active cervical lesion Herpes C/S 4 hr. ROM
- Manifestation 3
1. SEM (Skin-Eye-Mucocutaneous) vesicles , DOL 6-9
2. CNS DOL 10-14
3. Disseminated w/in 1 wk.
Vomiting
- Vomiting VS Regurgitation ()
Regurgitation ; stomach
Vomiting abdominal m. stomach /
- : bile / bile / blood
1. bile
- Inflammation & infection NEC, sepsis, AF /
- Metabolic & endocrine Inborn errors of metabolism, Adrenal insufficiency
- Neuro IICP (HCP, anomaly, hemorrhage), Infection (meningitis, encephalitis), Kernicterus
- Gut obstruction ( proximal) Esophageal atresia, Pyloric stenosis
2. bile
- Inflammation & infection NEC
- Ileus
 TOP SI 117

- Neuro IICP
- Gut obstruction ( opening of bile duct) Intestinal atresia, Malrotation, Meconium
plug syndrome, Hirschsprungs disease
3. blood
- Blood Coagulopathy GI bleeding / , NEC, Gastric volvulus,
irritate stomach (e.g. NSAIDs)
- Blood ( Apt test), cracked nipple
- Initial management
1. PE: V/S (Blood loss, Infection), Abdomen (Mass, Gut obstruction, Bowel sounds; Hyperactive
bowel sounds surgical condition), Neuro (Meningeal irritation, IICP, Bulging fontanelle)
2. position: aspiration
3. NPO + + OG/NG decompression
4. IV fluid
5. Investigation: Acute abdomen series, CBC, Apt test
- Definite treatment:
Abdominal distension
- Abdominal distension ( normal ,
stool )
- cause
Gut obstruction ( distal) Hx delayed pass meconium in 48 hr., NEC, Sepsis, GI perforation

Organ PKD, Neuroblastoma, Hepatosplenomegaly
- Initial management
1. PE: V/S, Abdomen
2. NPO + OG/NG decompression ()
3. IV fluid
4. Investigation: Acute abdomen series, etc.
Necrotizing enterocolitis (NEC)
-
1. Intestinal ischemia (Preterm, IUGR, Perinatal asphyxia, Polycythemia)
2. Abnormal bacterial flora ( Broad-spectrum ATB)
- NEC DOL 1-2 (term), DOL 7-10 (preterm)
( Preterm Preterm NPO DOL
7-10 step )
- Common VLBW (< 1,500 g)
- common Terminal ileum & Ascending colon
 TOP SI 117

- risk , Rate step (/)

- S&S: non-specific (Hypo-/Hyperthermia, , , Abdominal distension + tenderness,
Hypoactive bowel sounds, Vomiting)
- Investigation
1. Film abdomen
1) Bowel dilatation F/U film dilate = Fixed loop dilate ( bowel
inflammation )
2) Pneumatosis intestinalis air bowel wall bowel increased
distance between adjacent bowel, bowel wall edema
3) Pneumoperitoneum Football sign, Double wall sign ( air intra &
extraluminal ), Falciform ligament sign
Film Lt. Lateral decubitus () air liver
4) Portal venous gas ( severity) air Portal v. severe, Pneumobilia
( air Portal system)
2. CBC Platelet , severe WBC
3. Electrolyte Metabolic acidosis, HypoNa+
4. Septic W/U source : H/C, Urine C/S, CSF C/S
(NB infection sepsis LP C/I)
5. Coagulogram: severe
- Modified Bell staging
Stage 1 (Suspected): Symptom (, stomach), Film

Stage 2 (Definite): Symptom + Film: Pneumatosis intestinalis
2A ( Stage 1)
2B V/S , , Film: Portal venous gas,
Stage 3 (Advanced): (e.g. V/S , Hypotension, Metabolic acidosis , Oliguria,
Shock, Apnea), Film
3A Bowel perforate
3B Bowel perforate
- Management
1. NPO + OG decompression
2. position:
3. IV fluid, TPN
4. V/S, Initial management
1) T: T incubator radiant warmer
2) RR: position on ETT
3) BP, P: BP , P , HR Shock load IV fluid
 TOP SI 117

4) Correct Metabolic acidosis, Electrolyte imbalance, Abnormal coagulogram

5. Specific treatment
1) ATB 1st line: Ampicillin + Gentamicin; severe add Metronidazole Clindamycin
cover Anaerobe ; duration severity & response
2) severe , response ATB Sx: Bowel resection
- Prevention: (, bowel Abdominal distension
, , bowel sounds ), risk ,
(10-20 cc/kg/d) step ( 20 cc/kg/d)
Preterm
- Preterm risk
1. RDS surfactant
2. IVH 7 d , Dx U/S, 4 grades
3. NEC common VLBW; risk , rate step
4. Metabolic: Hypoglycemia, HypoCa2+ (Ca2+ 3rd trimester)
HypoCa2+ NB 10% Ca gluconate 2 cc/kg (= 200 mg/kg) IV push IV
drip ( 2 cc/kg hypoglycemia)
5. AOP Dx criteria Apnea & R/O 2 cause
AOP onset 24 hr. cause
Dx AOP
6. ROP O2 hyperoxia NV (neovascularization) retina
GA < 32 wk. BW < 1,500 g 4 wk., F/U
Retinal vessel mature
ROP Laser RD (retinal detachment) blind
7. PDA Lt.-to-Rt. shunt ( PVR ) HF
Preterm GA 34 wk. RDS / Dexa. D.3 lung PVR
Lt-to-Rt. shunt PDA Dexa. RDS
PDA Lt.-to.Rt. shunt
8. BPD Chronic lung disease; Dx O2 28 d (
DDx Respiratory distress )
GA < 28 wk. PCA 36 wk. O2 Dx BPD: severity Mild
( RA ), Moderate (off tube ), Severe ( on tube )
9. Sepsis
10. Feeding intolerance
Congenital diaphragmatic hernia (CDH)
- CDH 2
1. Isolated CDH (60%)
2. Complex CDH (40%) other organ defects, genetic disorders (e.g. trisomy)
 TOP SI 117

- CDH survival Lung size + Lung function

- Lung function impaired PPHN
Maternal diseases
- Maternal DM NB Macrosomia, SGA / LGA, Hypoglycemia, Polycythemia, Organomegaly
( splenomegaly Plt ), HOCM, RDS ( delayed lung maturity), Sacral agenesis
- Maternal PROM NB , OG content cell (fresh & G/S) fresh WBC 5-
10/HP +ve
- Maternal SLE (esp. Active SLE, Anti-Ro / Anti-La +ve) NB 3rd degree AV block (
observe HR) AV block ( irreversible) pacemaker
present wk.3-4 present
- Advanced maternal age (AMA (esp. > 35 yr.) Chromosome abnormalities
New mutation Dominant gene
 TOP SI 117

Cardiology
- pulse brachial a. femoral a.
- Active precordium NB sign PDA
- Femoral pulse NB: CoA; PDA
- Innocent murmur (Functional murmur) = murmur flow
1. Systolic murmur Venous hum innocent murmur Continuous murmur
( Diastolic / Pansystolic / Late systolic / Continuous murmur Venous hum)
2. Gr. 3
3. heart
4.
- Venous hum = blood flow Internal jugular v. Continuous murmur
Venous hum PDA
: murmur Jugular v. murmur
Venous hum ( PDA murmur )
Venous hum supine position murmur
- Hemic murmur = innocent murmur anemia, anemia
: Anemia (Hct ) Blood viscosity , TPR SV & C.O. , Velocity flow
Turbulent flow (esp. Aortic valve & Root of ascending aorta velocity
flow ) soft SEM
Congenital heart disease (CHD)
- Approach
1. Heart
2. Heart Congenital Acquired
( Acquired heart disease RF, Myocarditis, KD, etc.)
3. Congenital ( present 1-2 yr. ) Cyanotic Non-cyanotic
4. Cyanotic Refer
- Cyanotic heart diseases: 5T
1. Tetralogy of Fallot (TOF)
2. Transposition of great arteries (TGA)
3. Tricuspid atresia (TA)
4. Truncus arteriosus
5. Total anomalous pulmonary venous connection (TAPVC)
6. Common ventricle
- Non-cyanotic heart diseases 3
1. Lt.-to.Rt. shunt: ASD, VSD, PDA, PAPVC HF
2. Obstructive disease: AS, PS, CoA CoA
 TOP SI 117

3. Valvular heart disease: MR, TR, ECD ( Down syndrome)

- CHD (Lt.-to-Rt. shunt: e.g. VSD, ASD, PDA, Truncus arteriosus, Common
ventricle) PHT resistance (PAP) reverse shunt
aorta ( Rt.-to-Lt. shunt) = Eisenmenger syndrome (Pulmonary vascular obstructive disease,
PVOD)
Tetralogy of Fallot (TOF)
- TOF 4
1. Large VSD Lt.-to-Rt. shunt
2. PS severity ( PS )
3. RVH VSD + PS
4. Overriding aorta
- PE: Cyanosis (vary degree), Clubbing of fingers, Single S2, SEM at LUPSB
- Cyanosis 2-3 mo. , Squatting (), Dyspnea on
exertion (DOE), Hypoxic spell
- CXR: Boot-shaped heart
- Management: Modified Blalock-Taussig shunt (MBTS) = Subclavian a. (br. Aorta)
Pulmonary a. lung O2
PS VSD cyanosis
- Shunt MBTS Shunt murmur Continuous murmur at RUPSB ( RMBTS)
/ Shunt murmur shunt
Shunt murmur shunt
- MBTS heart murmur 2
1. Continuous murmur at RUPSM (Shunt murmur)
2. PSM at LLPSB ( VSD)
Transposition of great arteries (TGA)
- PE: Single & loud S2; EKG RVH ( RV systemic )
- CXR: Oval-shaped heart silhouette with narrow cardiac base (vessel ) = Egg on
string
Total anomalous pulmonary venous connection (TAPVR)
- TAPVR = PV drain RA ( LA); 4 types
1. Supracardiac (50%) PV Ascending vertical v. Brachiocephalic v. Rt. SVC RA
2. Cardiac (20%) PV RA Coronary sulcus
3. Infracardiac (20%) PV Descending v. Hepato-portal system IVC RA
4. Mixed PV drain RA 1 types
- CXR: Snowman sign Figure of 8 (Supracardiac type)
Ventricular septal defect (VSD)
 TOP SI 117

- VSD CHD ; 4 types

1. Type 1: Outlet (Subpulmonary, Subarterial)
2. Type 2: Perimembranous
3. Type 3: Inlet
4. Type 4: Muscular
- PE: PSM at LLPSB; moderate-large VSD CHF 6-8 wk., loud P2 LLPSB,
mild diastolic rumbling murmur apex ( relative MS)
- VSD present ~ 3-6 mo. ( pulmonary P )
- moderate-large VSD > 2 Eisenmenger syndrome
- PA/VSD (Pulmonary atresia with VSD) Cyanotic heart disease ( PA)
Management: MBTS; S/P MBTS Shunt murmur (Continuous murmur at RUPSB) murmur
VSD (PSM at LLPSB) / Shunt murmur shunt
(PA/VSD TOF)
Atrial septal defect (ASD)
- ASD 4 types
1. Primum
2. Secundum
3. Sinus venosus
4. Coronary sinus
- PE: SEM at LUPSB, wide splitted & fixed S2
- ASD present
Patent ductus arteriosus (PDA)
- PDA small asymptomatic, moderate-large CHF
- PE: Continuous murmur at Lt. infraclavicular area, Bounding pulse, Wide PP (PP > 25 mmHg)
Coarctation of aorta (CoA)
- 30% Turner syndrome CoA
Acquired heart disease
Rheumatic fever (RF)
- Rheumatic fever (RF) > 5 yr.; Mitral valve
MR AR RF
- Dx Modified Jones criteria: RF 2 Major 1 Major + 2 Minor
Major criteria (----)
1. Chorea
2. Subcutaneous nodule
3. Carditis (Endo/Myo/Peri)
 TOP SI 117

Endocarditis Murmur
Myocarditis Clinical HF, TnT, CK-MB
Pericarditis Pericardial effusion Pericardial rub, Distant heart sound, Cardiac tamponade
4. Polyarthritis
5. Erythema margitanum
Minor criteria
Clinical
1. Fever
2. Arthralgia
3. Hx of RF of RHD
Laboratory
1. ESR, CRP (Acute phase reaction)
2. Prolonged PR interval
- Supporting evidence of GAS infection ( RF sequelae GAS infection)
1. ASO titer, Anti-DNaseB
2. Throat swab for C/S ( 20% GAS carrier)
3. Recent Scarlet fever
- Investigation: CXR, EKG, Echo.
- Prophylaxis Dx RF
1. Carditis 5 yr. 21 yr.
2. Carditis + no residual 10 yr.
3. Carditis + residual (valve ) > 10 yr. 40 yr. life-long
Kawasaki disease (KD)
- Kawasaki disease (KD, Mucocutaneous lymph node syndrome) criteria Dx
1. Fever 5 d
2. 4/5
1) Bilateral nonexudative conjunctival injection
2) Changes in lips, tongue, or oral mucosa (e.g. Injection, Drying, Fissuring, Strawberry tongue)
3) Changes in peripheral extremities (e.g. Edema, Erythema, Desquamation)
4) Polymorphous truncal exanthem
5) Cervical Lymphadenopathy (at least 1 node 1.5 cm)
Criteria KD Mucocutaneous lymph node syndrome
Muco (2 ) = ,
Cutaneous (2 ) = -//,
Lymph node (1 ) = LN
4 5 criteria + 5 d Dx KD
- infant & pre-school
 TOP SI 117

- Dx KD refer IVIG D.10

- DDx: KD, TB LN, Scrub typhus, Lymphoma, Viral exanthem, Drug reaction, SSSS, Scarlet fever
Ix: CBC, PBS, CXR, U/A, LFT, Echo.
- Echo. 3 : 1st Dx, 2 wk., 6-8 wk.
- Management
1. IVIG 2 g/kg 2 hr. (test hr. )
2. ASA 80 MKD
3. F/U Echo, ESR, CRP
Pediatric cardiac emergencies
Congestive heart failure (CHF)
- Cardinal signs of CHF
1. Tachycardia
2. Tachypnea
3. Cardiomegaly (apex shift)
4. Hepatomegaly (hard consistency)
- CHF 2
1. High-output heart preload P heart e.g. VSD, ASD, PDA, Lt.-to.Rt.
shunt
2. Low-output heart obstruction , Myocarditis
- PE: S3 gallop, Fine crepitation, Wheezing (Cardiac asthma)
- Investigation
1. CXR: Cardiomegaly (CT ratio > 0.5 > 0.55 NB)
2. EKG: U/D
3. Echocardiography Gold standard
- FTT
- Management
1. Specific treatment: cause
2. Symptomatic treatment
1) Physical activity + O2
- , Semi-Fowler position ( 45, 15) venous return
- O2 ( on Ventilator + PEEP Pulmonary edema)
- Analgesic
- sedate: MO 0.05-0.1 mg/kg ( SVR, , Atrial P )
- T
- Infection, Hypoglycemia, Electrolyte imbalance
2) Volume overload
 TOP SI 117

- Restrict fluid 50-80% Maintenance

- Low salt diet: Na+ < 2 mEq/kg
- Lasix 0.5-1 mg/kg IV
3) Contractility: Inotrope
- Dopamine ( Vasoconstriction )
4) Afterload: Vasodilator
- ACEI Hydralazine ( Reflex tachycardia O2 consumption )
Cardiogenic shock
- Cardiogenic shock = heart pump , C.O.
( Preload, Afterload, Contractility, HR )
- Management
1. Specific treatment: cause
2. Supportive treatment
Hypoxic spell
- Hypoxic spell = cyanosis
- Prototype TOF Infundibular spasm ( shunt )
- S&S: Kussmaul breathing ( Metabolic acidosis), Cyanosis, , , Systolic murmur PS

- Precipitating cause: ,
- self-limited: 15-20 min; Hx
- Management ( heart , heart )
1. Knee-chest position SVR, Systemic venous return
2. O2 Hypoxia
3. MO 0.1-0.2 mg/kg IM / IV Sedation
4. NaHCO3 1-2 mEq/kg IV push Metabolic acidosis
5. Propanolol IV 0.1 mg/kg dilute 10 cc IV push Infundibular spasm ( TOF)
6. Raise systemic BP /
7. Anemia (Hct < 50-55%): PRC 10 cc/kg
Polycythemia (Hct > 65%): Bloodletting 10 cc/kg
8. Paralyze + Ventilate
9. Emergency palliative shunt Sx: Modified Blalock-Taussig shunt (MBTS)
 TOP SI 117

Gastroenterology & Nutrition

- = Ectomorphy; = Mesomorphy; = Endomorphy
- CHO, Protein, Fat
= 2, 4, 6
= 4, 4, 4
Diarrhea
- Bloody diarrhea
Infectious cause
- Bacteria: EHEC, EIAC, Shigella, Campylobacter jejuni, Yersinia enterocolitica
- Protozoa: E. histolytica, Trichuris trichiura, C. difficile ( Hx ATB )
- Viral: CMV ( immunocompromised)
Non-infectious cause Hemorrhoid, Anal fissure, Tumor, IBS (UC, Crohns)
Rotavirus infection
- Rotavirus diarrhea 3-5 d
- Rotavirus intestinal villi 2 Lactase deficiency
- LF formula Stool reducing +ve, pH < 5.5
- Rotavirus admit Contact precaution
Salmonella infection
- S. enterica diarrhea ATB , ATB prolonged carrier stage
- ATB Salmonella 3
1. Immunocompromised host
2. Age < 3 mo.
3. Hx of Recurrent Salmonella infection
Overfeeding
- Overfeeding () diarrhea enzyme Lactase

1. ( diarrhea infection )
2.
3. lactic acid ( ferment bact.)
4. Stool exam: Lactic acid, pH , Benedict +ve
- LF formula
Jaundice
- Total exchange bilirubin Kernicterus
- Jaundice
1. Breastfeeding jaundice
 TOP SI 117

- Onset
- Hx bile Enterohepatic circulation
absorb bile Jaundice
Dx Breastfeeding jaundice Breastfeeding
supplement
2. Breast milk jaundice
- Onset mo.
- Hx Glucuronyl transferase inhibitor conjugated IB DB
IB Jaundice
- Breastfeeding & Breast milk jaundice Phototherapy, Phenobarbital
- IV fluid
Replace bile NSS
Replace gastric content N/2
Short bowel syndrome
- Dx SB < 50%
- : Peptamen junior MCT
Protein-energy malnutrition (PEM)
- Waterlow classification malnutrition Weight for height (%W/H) & Height for age (%H/A)
Normal Mild Moderate Severe
%W/H 100 10 (90-110) < 90 < 80 < 70
%H/A 100 5 (95-105) < 95 < 90 < 85
Acute PEM %W/H = Wasting
Chronic PEM %H/A = Stunting (Nutritional dwarf)
- Gomez classification malnutrition Weight for age (%W/A)
Mild Moderate Severe
%W/A < 90 < 75 < 60
- Welcome classification malnutrition %W/A & Edema ( hypoalbuminemia
protein)
%W/A No edema Edema
60-80 Undernutrition Kwashiorkor
< 60 Marasmus Marasmic kwashiorkor
- Marasmus: common < 2 yr.; %W/A < 60
1. Skin and bone appearance
2. Monkeys face appearance : , , ,
subcutaneous fat
 TOP SI 117

- Kwashiorkor: common > 3 yr.; %W/A 60-80; protein, energy ()

1. Generalized edema ( pitting edema) serum albumin ( Marasmus
serum albumin /)
2. Dermatosis () , , (Hyperkeratosis), (Hyperpigmentation) dermis
() infection
3. Flag sign ( protein
protein)
4. Fatty liver fat , serum FFA
5. Abdominal distension distension stomach & bowel, peristalsis
- PEM 40% Vitamin A Vitamin A S&S
- Severe PEM admit Life-threatening condition & Diet therapy ()
 TOP SI 117

Respiratory Medicine
- Dose
1. Paracetamol syrup (120 mg/5 ml = 1 tsp) 10-15 MK/dose
(e.g. 10 kg 100-150 mg/dose = 1 tsp)
2. Ventolin 0.03 MK/dose
(e.g. 10 kg 0.3 mg/dose Ventolin 0.3 mg NSS 3 cc q 4/6/8 hr.
severity)
3. Amoxicillin (125 mg/5 ml = 1 tsp) 40-50 MKD tid
(e.g. 10 kg 400-500 mg/day = 1 tsp tid)
4. Cloxacillin syrup (125 mg/5 ml = 1 tsp) 50-100 MKD qid
(e.g. 10 kg 500-1,000 mg/day qid = 1 tsp qid)
5. Bactrim 8 MKD qid
6. Pseudoephedrine 4 MKD
7. Carbocysteine ( 10 kg tsp)
- poor air entry () sign upper airway obstruction
- (high CO2) , aspirate
= Sudden infant death syndrome (SIDS)

- FB aspiration 1-3 yr. ()
- oral T 5 yr. ()
Upper respiratory tract infections (URI)
- URI typical (3-5-7)
3 d
5 d
7 d
> 2 wk. Sinusitis
Hx URI 1 mo. URI
( Ag ;
1 mo. Dx URI )
-
+ Rhinopharyngitis
Epiglottitis
- Epiglottitis: X-ray Thumb sign
Croup
- Croup (Acute laryngotracheobronchitis) PIV 1, 2, 3; triad
1. Hoarseness
 TOP SI 117

2. Inspiratory stridor
3. Barking cough
- 6 mo. 6 yr.
- Incubation period: 2-6 d, () 12-72 hr.
- DDx: Acute epiglottitis, Bacterial tracheitis, FB aspiration, RPA, Diphtheria
- X-ray: Pencil (Steeple) sign
- Downes croup score: C2RSI
Score 0 1 2
Cough Hoarseness Backing cough
Cyanosis Cyanosis in RA Cyanosis in O2 40%
Retraction & No Nasal flaring & 1 + Infrasternal &
Nasal flaring Suprasternal retraction Intercostal retraction
Stridor Inspiratory Inspiratory & Expiratory
Inspiration Normal Harsh with rhonchi
Score 0-3: Mild Supportive, , Advice
Score 4-7: Moderate Admit
Score 8-10: Severe on ETT
- Admission criteria: Progressive stridor, Severe stridor at rest, Respiratory distress, Hypoxia, Cyanosis,
Depressed mental status, Need for reliable observation
- Management
1. O2 + Mist therapy
2. IV fluid (Hydration)
3. ATB ( bacterial infection)
4. Closed observation, Downes croup score
5.
6. Steroid severe
7. Epinephrine (1:1,000) inflammation larynx
Acute Bronchiolitis
- 6 mo. 2 yr.; RSV
- S&S: , Wheezing, Increased AP diameter ( air trapping), Liver (
)
- CXR: Hyperaeration
Pneumonia
- Pneumonia criteria Dx
1. Fever ( 38C)
2. Tachypnea
 TOP SI 117

3. CXR: New infiltration (Abnormal lung sign)

- Viral pneumonia Viral AGE secretion
ATB
- S. aureus Pneumonia severe ( virulent ) Pneumothorax
- Measles pneumonia S. aureus superimposed ATB: Cloxacillin
Recurrent pneumonia
- Recurrent pneumonia criteria Dx
1. Pneumonia 2 episodes in 1 yr. 3 episodes ever with Confirmed abnormal CXR
2. Radiographic clearing of densities between occurrences
( CXR clear film film
abnormal 3-4 wk.)
- approach recurrent pneumonia
1. CXR same lesion different lesion
2. DDx
Same lesion
1. Intraluminal
2. Extraluminal
3. Structural airway
4. Parenchymal lesion
Different lesion
1. Chronic aspiration
2. Mucociliary dysfunction
3. CHD
4. BPD
5. Immunodeficiency (B cell)
(B cell deficiency onset 6 mo. 6 mo.
Maternal Ab 6 mo. T cell deficiency onset T cell
placenta )
Allergy
Allergic rhinitis (AR)
- Classification

1. Intermittent = < 4 d/wk. < 4 wk.
2. Persistent = > 4 d/wk. > 4 wk.

1. Mild = normal sleep, +
2. Moderate-Severe = abnormal sleep +
- Symptoms:
- Signs
1. Clear secretion
2. Nasal obstruction
3. Pale mucosa
- Hx: FHx of Allergy, , , , , ,
, Past medication, Drug allergy, Severity (, )
- PE: Skin ( ), Allergic shiner, HEENT, Adenoid hypertrophy
- Investigation: Anterior rhinoscopy, Allergic skin test, Nasal cytology
- Skin test ve Non-allergic rhinitis (Non-AR) = AR skin test ve
- Non-AR Nasal congestion, Rhinorrhea
( AR Sneezing, Itching )
- Management
1. Education
2. Advice: , (, ) , , ,
1-2 wk. 55C 30 min
3. severity
1) Intermittent, Mild AH1 (2nd-3rd Gen.)
Cetirizine (Zyrtec)
Age 2-5 yr. 2.5 mg OD pc
Age 6 yr. 5-10 mg OD pc
Loratadine
BW < 30 kg 5 mg OD pc
BW > 30 kg 10 mg OD pc
( Pseudoephedrine SE: Tachycardia)
2) Moderate-Severe ICS
4. Sinusitis treat Amoxicillin high dose 80-100 MKD bid PO 2-3 wk.
5. F/U 5-6 d
Sinusitis
- Classification
1. Acute < 1 mo.
2. Subacute 1-4 mo.
3. Chronic > 4 mo.
- most common 3 S. pneumoniae, H. influenzae, M. catarrhalis
- S&S:
1. Fever
2. Headache
3. Facial pain
4. Mucopurulent nasal discharge
- Dx clinical
- Investigation
- Acute imaging
- Chronic/persistent Coronal CT sinus
- Complications: COMBO
1. Cavernous sinus thrombosis
2. Orbital cellulitis
3. Meningitis
4. Brain/Subdural/Epidural abscess
5. Osteomyelitis
Asthma
- Chronic cough + Wheezing DDx 3
1. Asthma
2. GERD (Dx Ba swallowing & Esophageal pH monitoring)
3. Sinusitis
- Hx: Onset, Past medication, U/D, Hx & FHx of Allergy, Severity, Aggravating & Relieving factor, URI,
Infection, , , , , ,
, , Drug allergy, Vaccination
- 2 Risk factor & Long-term severity
1. Risk factor Early wheezer ( wheezing 3 yr.) Asthma
1 Major + 2 Minor risk factors
Major
1. Hx of AD
2. FHx of asthma
Minor
 1. Eo > 4%
2. Wheezing apart from cold
3. AR
2. Long-term severity
FEV1, Variability of

PEF FEV1, PEF
Mild 1 /wk.
2 /mo. < 20%
intermittent Brief exacerbation 80% of
Mild > 1 /wk. predicted
> 2 /mo. 20-30%
persistent /

Moderate , SABA , 60-80% of

> 1 /wk.
persistent predicted
, SABA , > 30%
Severe < 60% of

persistent predicted
Frequent exacerbation
- Asthma 3 components
1. Reversible airway obstruction
2. Airway inflammation
3. Bronchial hyperresponsiveness (BHR)
- Dx Asthma: 3R
1. Recurrence
2. Reactivity trigger
3. Responsive bronchodilator
- Siriraj Asthma score: WOR2D
Score 0 1 2
Wheezing - Expiratory Expiratory & Inspiratory
O2 sat. 95% 92-94% 91%
RR < 30/min 30-40/min > 40/min
(: Age < 5 yr.) < 40/min 40-60/min > 60/min
Retraction - 1 site > 1 site
Dyspnea - Mild Marked
Score 8 Bronchodilator at ER, Admit ICU
Score 7 Bronchodilator q 20 min 3 Re-evaluate
- Score 5 Admit
- Score = 4 Admit D/C H/M
- Score < 4 D/C H/M
- Management Asthma admit
 1. Supportive treatment: O2 supplement
2. Specific treatment: SABA, Anticholinergic, ICS
Early phase asthma (15-30 min) SABA
Late phase asthma (4-12 hr.) ICS
3. Treat cause (e.g. ATB infection)
4. Education, Advice: ,
5. F/U q 4 wk. control
- Investigation (Short-term & Long-term)
1. CBC Eo
2. U/A Asthmatic attack ( dehydration urine Sp.gr.)
3. CXR Normal Hyperaeration, Flattening of diaphragm, Peribronchial thickening
4. PFT (Spirometry) Gold standard
- Obstructive airway: FEV1/FVC < 0.8
- FEV1 variation 20%
- PEF 12%
- Exercise PEF 15%
5. Bronchoprovocation (Methacholine) challenge test
6. Peak expiratory flow (PEF) 3
Predicted PEF = (5 x Ht.)-400 (Ht. cm)

PEF variation (%) = ; Asthma PEF variation 20%
&
5. Skin prick test allergen ( house dust mite)
6. Nasal cytology
7. Stool exam ( CBC Eo parasite)
present Recurrent wheezing response W/U Vascular bl.vv.
heart position trachea airway obstruction wheeze ;
bl.vv. trachea cartilage trachea Tracheomalacia
Cow milk protein allergy
- Cow milk protein allergy Dx Goldmans criteria
- Definite Dx Food challenge test
- 3
1. IgE (w/in 1 hr.); Hypersensitivity type 1, IgE +ve, Skin prick test +ve
2. Non-IgE (> 3 hr.); Hypersensitivity type 4, IgE ve, Skin prick test ve
3. Mixed type Skin prick test ve
- ()
Soymilk 50%
- 80% 2-3 yr.
Urticaria & Angioedema
- Urticaria , , blanchable, 2-48 hr.; Acute ( 6 wk.) & Chronic (> 6 wk.)
- Angioedema , clinical: Wheezing
Anaphylaxis
- Anaphylaxis criteria Dx 3 ( 1/3 )
1. Acute onset (min-hr.) Skin, Mucosa or both involvement (generalized hives, pruritus & flushing,
swollen lip-tongue-uvula) 1/2
1) Respiratory compromise dyspnea, bronchospasm, stridor, reduced PEF, hypoxemia
2) Hypotension or End-organ dysfunction hypotonia, syncope, incontinence
2. Acute onset (min-hr.) expose Likely allergen 2
1) Skin-mucosa generalized hives, pruritus & flush, swollen lip-tongue-uvula
2) Respiratory compromise
3) Hypotension or End-organ dysfunction
4) Persistent GI symptom crampy abdominal pain, vomiting
3. Acute onset (min-hr.) expose Known allergen + Hypotension
Hypotension
Infant & Child Low SBP or SBP 30%
Adult SBP < 90 mmHg or SBP 30%
- Pathophysiology: IgE-mediated
( Anaphylactoid = Anaphylaxis immune)
- common: Insect sting, Food, Drug (ATB, NSAIDs)
common: Physical trigger (e.g. Exercise-induced anaphylaxis), Biological fluid (e.g.
Transfusion, Ig)
- Dx criteria Investigation confirm
1. Serum tryptase peak 60-90 min onset, 6 hr.; 2
2. Plasma histamine 5-10 min, 30-60 min 10 min 1 hr.
onset
3. Specific IgE ( , )
Skin prick test 2 wk. Anaphylaxis induce Anaphylaxis
2 wk., AH, skin lesion (+ve wheel 3 mm, flare
15 min)
Skin prick test Anaphylaxis ve specific IgE allergen
- Management
1. Primary survey (ABC)
A on ETT
B O2 therapy; SABA q 6 hr. (Ventolin0.05 MK/dose NSS 3 cc NB)
C Anaphylactic shock Resuscitation: IV fluid, Dopamine
 EKG abnormal Resuscitation
2. Medication
1) Adrenaline (1:1,000) 0.01 cc/kg IM; Max = 0.3 cc (child), 0.5 cc (adult)
Repeat 1-2 10-15 min
Anaphylaxis insect bite Adrenaline 0.005 cc/kg + Tourniquet q
10 min 1-2 min ( dose )
2) AH AH1 & AH2
AH1 Diphenhydramine 1 mg/kg IM / IV or CPM 5-10 mg IM / IV
AH2 Ranitidine 1 mg/kg IV slowly or Cimetidine 4 mg/kg IV slowly
3-4 d
3) Steroid Hydrocortisone 5 mg/kg or Methylprednisolone 1 mg/kg q 6 hr. (/
)
Prednisolone 1-2 MKD ( )

AH: CPM 0.35 MKD bid/tid, Ranitidine 2-2.5 MKD bid x 2 d
Steroid: Prednisolone 1-2 MKD x 2-3 d
urticaria / wheezing, CBC, Stool exam D/C , F/U 2 wk.
Allergy clinic
3. Advice (Prevention)
1) , , (, ,
),
2) (e.g. )
3) Adrenaline 1:1,000 0.01 mg/kg (EpiPen)
, AH & Prednisolone (oral)
4. F/U: Skin prick test Allergy clinic ( 2 wk. ) +ve
 TOP SI 117

Nephrology
Fluid replacement
- Fluid replacement = Maintenance (M) + Deficit (D) + Ongoing Loss (L)
- Maintenance (M) = fluid metabolism + + loss urine,
feces, insensible loss (ISL = 300 cc/m2/d)
admit replace ISL & urine output admit urine
output Oliguric urine output = 240 cc/m2/d)
- H2O Holliday-Segar law
10 kg 100 cc/kg
10 kg 50 cc/kg
10 kg 20 cc/kg
- Na+ 2-3 mEq/kg, K+ 1-2 mEq/kg
- M 1 3 8 hr.
- Deficit (D) severity dehydration
- Mild Flat fontanelle
- Moderate Marked dry lip/tongue, Sunken eyeball, Decreased urine output, Decreased skin
turgor, Orthostatic hypotension
- Severe BP drop, Anuria
- < 1 yr. deficit 5-10-15% severity
1 yr. deficit 3-6-9% severity
- isotonic dehydration: 100 cc H2O deficit Na+ 8 mEq/kg
- Deficit 1 8 hr. 16 hr.
- fluid replacement
Case: 2 15 kg 10 1 2 ,
last void 8 hr. .., PE: afebrile, P 130/min, BP 85/50 mmHg, marked dry lip, dry tongue, sunken
eyeball IV rate & strength admit
Maintenance
H2O: 15 kg 1,000 + 250 = 1,250 cc
Na+: 3 mEq/kg = 3 x 15 mEq = 45 mEq
Deficit
H2O: moderate dehydration, 1 yr. 6% = (6/100) x 15 x 1,000 ( L
cc x 1,000) 6 x 15 x 10 ( % x BW x 10) = 900 cc
Na+: 8 mEq/kg 100 cc H2O deficit H2O deficit 900 cc Na+ 8 x 9 (8 x H2O deficit/100) =
72 mEq

H2O M 1,250 cc, D 900 cc
 TOP SI 117

Na+ M 45 mEq, D 72 mEq

M 3 , D 8 hr. 16 hr.
8 hr. 8 hr. 8 hr.
M 416 416 416
H2O D 450 225 225
Total 866 1,282
M 15 15 15
+
Na D 36 18 18
Total 51 66
8 hr.
Rate: 866/8 = 108 cc/hr ~ 110 cc/hr
1,000
Strength: H2O 866 cc Na+ 51 mEq, H2O 1,000 cc (1 ) Na+ = x 51 = 58
866
mEq NSS 1 Na+ 154 mEq 154/58 ~ 3 strength = N/3
16 hr.
Rate: 1,282/16 = 80 cc/hr
1,000
Strength: H2O 1,282 cc Na+ 66 mEq, H2O 1,000 cc Na+ = x 66 = 51 N/3
1,282
order
5%D/N/3 110 cc/hr x 8 hr., then 5%D/N/3 80 cc/hr x 16 hr.
- Oliguria
Infant: Urine output < 0.5 cc/kg/hr
Child: Urine output < 1 cc/kg/hr
- Polyuria: Urine output > 4 cc/kg/hr
- Body surface area (BSA) 2
W Ht .
1. BW & Ht.: BSA = (Mosteller's formula)
3,600
4W +7
2. BW ( Ht.): BSA =
W +90
Sodium disorders
- Na+ 3
HypoNa+ Na+ = 0.6 x BW x Na+
e.g. BW = 10 kg, Na+ = 128 Na+ = 7 7 x 10 x 0.6 = 42 3 = 14 8
hr. ( Na+ deficit ); 10-12
135
HyperNa+ Free water = 0.6 x BW x 1
Measured Na
NSS free water N/2 free water
Free water = 1 L N/2 = 2 L
- Isotonic & Hyponatremic dehydration volume deficit in 24 hr.
Hypernatremic dehydration volume deficit in 48 hr.
 TOP SI 117

Potassium disorders
- HypoK+ K+ 1-2 mEq/kg
KCL 1 cc K+ 2 mEq ( IV)
- IV 1 K+ Max = 40 mEq/L Phlebitis central line
- Rate K+ Max = 0.5 mEq/kg/hr rate
Elixir KCl 15 cc K+ 20 mEq ()
(e.g. K+ = 3.1 () : K+ 1 mEq/kg, 10 kg K+ 10 mEq = Elixir KCl 7.5
cc)
- HyperK+ guideline
K+ 5-6 K+ intake < 0.5 mEq/kg/d & Lasix
K+ 6-6.5 add NaHCO3-, -agonist, Kalimate
K+ > 6.5 Ca gluconate, Glucose & RI, consider Dialysis
Acid-base imbalance
- acidosis urine urine RTA
(e.g. Proximal RTA PCT absorb HCO3- )
- RTA type 1 (Distal RTA) Distal tubule secrete H+ ; Nephrocalcinosis, U/S: Calcification
- RTA type 2 (Proximal RTA) Proximal tube reabsorb HCO3-
- Metabolic acidosis (e.g. MMA) FTT ()
Nephrotic syndrome (NS)
- NS 4
1. Nephrotic-range proteinuria
1) Urine protein > 40 mg/m2/hr > 50 MKD
2) Urine protein:Cr > 2 ( < 0.2)
2. Hypoalbuminemia Plasma albumin < 2.5 g/dl
3. Generalized edema
4. Hyperlipidemia Cholesterol > 250 mg/dl
- Sign Puffy eyelid ()
- urine sp.gr. < 1.015 protein 2+ significant
urine sp.gr. > 1.015 protein 3+ significant
- spot urine ( Urine protein:Cr) Morning urine Orthostatic
proteinuria (esp. )
- Nephrotic syndrome IgG, IgA IgE, IgM
- Complications: THAI+P
1. Thrombosis
2. Hypovolemia/Hypotension
3. Acute renal failure (ARF)
 TOP SI 117

4. Infection (peritonitis)
5. Protein depletion
- Management
1. Prednisolone 2 MKD (Max = 60 mg/d = 12 tab/d; 5 mg/tab) OD 4 wk. urine protein -ve 3
d ( 8 wk.)
m2 Prednisolone 60 mg/m2/d
2. Taper dose 2 MK AD ()
3. Taper dose off 6 mo.
- 90% responder remission (urine protein < 4 mg/m2/hr) 10-15 d
- 2 MKD OD 4 wk. remission = Steroid resistance (Steroid unresponsive)
urine protein remission +ve (e.g. 4+ 3+) = Late responder
- treat urine protein -ve +ve = Relapsed
relapsed 2 /6 mo. 4 /yr. = Frequent relapsed
- taper dose steroid (e.g. taper dose urine protein ) = Steroid dependent
treat urine protein negative try taper steroid taper urine protein positive
= Frequent relapsed Steroid dependent
- Late responder & Steroid resistance W/U Infection
Treat infection
add Cyclophosphamide (Endoxan) 2 MKD 12 wk. 3 MKD 8 wk.
- Renal biopsy
1. Steroid resistance
2. Frequent relapsed
3. Atypical case
4. start immunosuppressant Cyclosporine
Renal biopsy NS Minimal change disease (MCD)
Renal biopsy 4
- Albumin NS I/C
1. Intravascular volume depletion
2. S&S of volume overload e.g. Respiratory distress Pulmonary edema, Ascites)
( Albumin oncotic P intravascular)
3. Genitalia swelling Torsion testis, Infection
4. Acute renal failure (ARF)
- volume 5% Albumin
volume 20% Albumin
- NS Ascites Peritonitis most common S. pneumonia
Pneumococcal vaccine Dx NS
Peritonitis
 TOP SI 117

- I/C refer NS
1. Age < 1 yr. > 10-12 yr.
2. Persistent HT
3. Gross hematuria
4. Low C3 / C4
5. Steroid resistance
Glomerulonephritis (GN)
Acute post-streptococcal glomerulonephritis (APSGN)
- APSGN Pharyngitis 1-2 wk., Ecthyma 3-6 wk.
- APSGN clinical + (e.g. ) hematuria (
microscopic hematuria)
- Investigation
1. U/A, Serum complement (C3)
C3 Active SLE & APSGN
2. Supporting evidence
1) ASO titer ( Pharyngitis), Anti-DNaseB ( Pharyngitis & Ecthyma)
ASO, Anti-DNaseB > 20% UNL
2) Throat swab for C/S ( 20% GAS carrier)
Ecthyma swab C/S
3. Complication: CXR, BUN/Cr, Serum electrolyte, CBC
4. SLE ANA, Anti-dsDNA
- Management
1. ATB: Amoxicillin 10 d ( Macrolides)
2. decreased GFR
- HT Lasix 1-2 mg/kg IV Short-acting anti-HT (Hydralazine 0.1 mg/kg IV
Nifedipine 0.25 mg/kg SL)
- Pulmonary edema O2 + MO
3. IV fluid ISL (300-400/m2/d) Oliguric urine output (240/m2/d)
4. Restrict fluid
5. Correct electrolyte (e.g. HyperK+; K+ monitor EKG )
- F/U: Clinical 1 wk., Hematuria 2-3 wk.
F/U U/A, BUN/Cr, V/S, Sao2, Complication HT (e.g. Hypertensive retinopathy,
Hypertensive encephalopathy, Seizure, Severe headache)
Rapid progressive glomerulonephritis (RPGN)
- RPGN 3
 TOP SI 117

1. Anti-GBM Ab GBM; Hypersensitivity type 2; Goodpasture

syndrome: involve RS Pulmonary hemorrhage
2. Immune complex Hypersensitivity type 3; APSGN, IgA nephropathy, SLE
3. Pauci-immune (ANCA associated) (ANCA = Anti-neutrophil cytoplasmic Ab) Hypersensitivity
type 2;
1) Wegener granulomatosis Goodpasture syndrome, involve RS
2) Microscopic polyangiitis inflammation bl. vv.
3) Churg-Strauss syndrome 2 Hx Asthma & CBC
Eosinophil
- Pathology: cell Bowmans capsule glomerular injury
Crescent GFR volume overload Lasix (
pathology urine ) & Anti-HT long-acting CCB Amlodipine
- RPGN I/C Renal biopsy
Systemic lupus erythematosus (SLE)
- SLE criteria 11 ( 4/11)
Skin criteria
1. Malar rash butterfly rash, spare nasolabial fold
2. Discoid rash erythematous-raised patches with keratic scaling & follicular plugging
3. Photosensitivity
4. Painless oral ulcer
Systemic criteria
5. Non-erosive arthritis oligoarticular ( 2 jt.), episodic, migratory, symmetrical
6. Serositis: Pleuritis ( pleuritic chest pain, evidence of pleural effusion), Pericarditis ( pericardial
effusion, EKG PR depression, electrical alternans)
7. Renal disorder persistent proteinuria ( 3+ > 0.5 g/d), cellular cast
8. Neurological disorder seizure, psychosis identify cause
Laboratory criteria
9. Hematologic disorder
1) AIHA (DAT +ve)
2) Leukopenia (WBC < 4,000)
3) Lymphopenia (L < 1,500)
4) Thrombocytopenia (Plt < 100,000)
10. ANA +ve
11. Immunologic disorder
1) Anti-dsDNA +ve
2) Anti-Sm +ve
3) Antiphospholipid Ab +ve (1) Anti-cardiolipin IgG or IgM, (2) Lupus anticoagulant (LA),
 TOP SI 117

(3) False positive serological test for Syphilis > 6 mo. (VDRL +ve; TPHA -ve)
- DDx: Henoch-Schnlein purpura (HSP), Polyarthritis nodosa (PAN), Rheumatic fever (RF), Juvenile
rheumatoid arthritis (JRA)
- ANA sense 95% screen false positive neoplasm, chronic infection, other autoimmune
- active 2 Complement level (C3) & Anti-dsDNA
- SLE
1. Hydroxychloroquine 5-7 MKD: Skin lesion (esp. Discoid rash) / Arthritis / DLP /
Renal progression
( Eye exam Hydroxychloroquine SE: Retinopathy)
2. NSAIDs arthralgia, myalgia ASA 60-80 MKD Indomethacin 75-150 mg/d
3. Topical steroid skin involvement 0.1% 0.02% TA cream
4. Systemic corticosteroid Prednisolone
( Stool exam Prednisolone)
- Advice: , , ,
- Renal biopsy SLE I/C
1. Steroid high dose No response
2. Nephrotic nephritis
- LN (Lupus nephritis) class 3, 4 Steroid high dose + Cyclophosphamide (Endoxan)
Cyclophosphamide SE: Hemorrhagic cystitis
hydration 6 hr. Hemorrhagic cystitis IV hydration
F/U 2 wk. CBC ( Nadir period ANC
dose FN; F/U 2 wk. CMT WBC
10-14 d )
- ESR F/U ; treat ESR < 20
- U/A profile RBC proteinuria
Hypertension (HT)
- Normal BP BP < P90
- HT = BP > P95; renal cause;
1. HT stage 1: P95-99 + 5 mmHg
2. HT stage 2: > P99 + 5 mmHg
(P95 + 7 = P99)
- Pre-HT = P90-95 BP > 120/80 mmHg ( P90)
- Hypertensive urgency = P99 + 5 Management: Nifedipine (Adalat) (Short-acting CCB)
complication HT
Goal: BP 1/3 6 hr. Optimal BP 24-72 hr.
 TOP SI 117

- Hypertensive emergency = HT + Target organ damage Management: Nicardipine IV, q 5-

10 min ( BP )
Target organ damage:
Brain Hypertensive encephalopathy
Kidney ARF
Eye Hypertensive retinopathy (grade 4: Papilledema)
Heart Hypertensive cardiomyopathy, HF, Pulmonary edema
Goal: BP 1/4 (25%) 8 hr. Optimal BP 24-48 hr.
- Cuff ( Sphygmomanometer) BP
1. cuff bladder ( cuff) ~ 40%
acromion & olecranon
2. ~ 80-100%
cuff BP (error error cuff
BP )
- Ambulatory BP monitoring (ABPM) = BP 24 hr.
1. Dx White-coat HT
2. BP BP e.g. Chronic kidney disease, DM
3. BP Hypotension Anti-HT drug
- Approach
1. Hx:
- GU: / / / / (flank pain)
- U/D, Drugs, Na+ intake
- Symptoms of target organ damage (, , , )
- Chronic renal failure (polyuria, polydipsia, weight loss), Hyperthyroid ( )
- FHx of HT, DM, MI, Stoke
- Hx of UVC ( Renal a. thrombosis)
2. PE:
- V/S: Tachycardia Hyperthyroid, Pheochromocytoma
Pulse -, BP 4 extremities; BP < CoA
- Ht. & BW:
Growth retardation Chronic renal failure
Obesity Essential HT
Truncal obesity Cushing syndrome
- Skin:
Pale, flushing, diaphoresis Pheochromocytoma
Caf-au-lait spot NF
- CVS:
 TOP SI 117

Murmur CoA ( VSD )

Apical heaving LVH, Chronic HT
- Abdomen:
Mass Wilm tumor, Neuroblastoma ( Renal a.), Pheochromocytoma
Epigastric / Flank bruit Renal a. stenosis
Palpable kidney PKD, Hydronephrosis
- Genitalia: Ambiguous / Virilization CAH
- ()
NB Renal a. stenosis / thrombosis ( UVC), Congenital anomalies
Age 1 yr. CoA, Renovascular disease, Renal parenchymal disease
Age 1-6 yr. Renal parenchymal disease, Renovascular disease, CoA
Age 6-12 yr. Renal parenchymal disease, Renovascular disease, Essential HT, CoA
Age 12-18 yr. Essential HT, Iatrogenic, Renal parenchymal disease, Substance abuse, Endocrine
disorder (CAH, Pheochromocytoma)

1. < 12 yr. (esp. 1 yr.) CoA BP 4 extremities
2. Renal parenchymal disease & Renovascular disease 1-12 yr.
3. Essential HT 6 yr.
4. Substance abuse
- Investigation
1. Basic lab
- U/A ( UTI), BUN/Cr ( Renal function), Electrolyte
- CXR ( Cardiomegaly), EKG ( LVH)
- FPG, Lipid profile
- Fundoscopy ( Retinopathy)
- U/S KUB
2. Test for specific cause: Renal a. stenosis ( HT, Hx , lab )
Renal studies: Renal U/S, Captopril renogram then Renal angiography
- Management
1. Non-pharmacological intervention: Lifestyle modification (LSM)
- Diet: , low salt, low fat, high fiber
- Exercise: 30-60 min/d
( HT stage 2 BP BP shoot)
- Activity: TV, games ( 2 hr/d)
2. Pharmacological therapy: I/C for Anti-HT drug ( HT) 6
1) HT stage 2
2) HT stage 1 Non-pharmacological
 TOP SI 117

3) Symptomatic HT
4) 2 HT
5) Target organ damage
6) DM
- DM type 2 / proteinuria -blocker
- Headache / Migraine CCB
- DM type 1 / Asthma / Heart block -blocker
- Goal:
- Essential HT complication, target organ damage (e.g. LVH) BP < P95
- HT Target organ damage / HT Chronic kidney disease / DM BP < P90
 TOP SI 117

Endocrinology
Hypoglycemia
- NB Maternal DM, Macrosomia ( hyperinsulinism); persistent
PHHI
- DDx:
1. Insulinoma
2. Pituitary tumor
3. Glycogen storage disease (type 1 severe , type 6, 9 adult, PE: Hepatomegaly)
4. Fatty acid oxidation defect (defect Lipolysis & Ketogenesis; Hx Prolonged fasting 10-12 hr. &
hypoglycemia; Hepatic failure, Cardiomyopathy)
5. Drugs
1) DM
2) HT (-blocker)
3) Salicylate ( Hepatic gluconeogenesis; Hx / Salicylate)
- Hyperinsulinism test Fasting test: fasting hypoglycemia insulin;
fasting
Age < 1 yr. Fasting 12-18 hr.
Age > 1 yr. Fasting 24 hr.
Adult Fasting 72 hr.
- Fasting test Urine ketone ketone
Hyperinsulinism ( Insulin Ketogenesis) test
Persistent hyperinsulinemic hypoglycemia of infancy (PHHI)
- PHHI most common cause persistent hypoglycemia < 1 yr.; Hx GFR
hypoglycemia 10%D/W strength central line
- Pathophysiology: PPHI K+-ATP channel -cell (
ATP K+ cell)
K+-ATP channel: Glucose GLUT2 -cell Glucose
Glycolysis ( enz. Glucokinase) ATP ATP K+-ATP channel channel K+
cell Depolarization Ca2+ channel Ca2+ cell Insulin
- PHHI Lab. Ketone ( Insulin Ketogenesis) = Nonketotic hypoglycemia

Counter-regulatory hormone (isolated) Ketone
Panhypopituitarism Ketone ve ( PHHI)
- Blood glucose < 50 mg/dl (Hypoglycemia) Insulin level < 2
Blood glucose < 50 mg/dl (Hypoglycemia) Insulin level > 2 = Hyperinsulinism
 TOP SI 117

- Management: Diazoxide K+-ATP channel Nifedipine (Adalat) (CCB) block

Ca2+ cell insulin
- Sx Pancreatectomy
Thyroid disorders
Congenital 1 hypothyroidism
- Cause: 80% Thyroid dysgenesis (1:4,000; agenesis/hypoplasia/ectopia) Thyroid
dyshormonogenesis (1:30,000)
- S&S: , , Fontanelle , , Poor feeding, Prolonged jaundice, Tongue
enlargement, Hoarseness, Dry skin, Umbilical hernia, Constipation, Hypoactive, Poor weight gain,
Delayed development, Respiratory distress, Bradycardia, Weakness
- Newborn screening: 1 TSH approach 2-4
; TSH
: Compensated 1 hypothyroidism
: Central hypothyroidism, Hypothyroixinemia in prematurity, TBG deficiency
screen Combined 1 TSH + T4 approach TSH
- TSH 18 mU/L abnormal
- Investigation: TSH abnormal ( 18 mU/L)
1. Hx Graves' disease PTU Transient 1 hypothyroidism
2. PE 10% S&S , growth & development
3. Lab
1) Serum TSH & T4/FT4 normal
2) Thyroid scan
- Uptake Dyshormonogenesis, Transient hypothyroidism
- Uptake Ectopic thyroid gland ( L-thyroxine )
- No uptake Thyroid U/S thyroid gland
- Thyroid gland Dyshormonogenesis, Transient hypothyroidism
- Thyroid gland Thyroid agenesis
( Thyroid scan, U/S L-thyroxine )
Bone age X-ray bone age 50%
- Management
- L-thyroxine 10-15 MKD (initial dose)
- serum T4 10 g/dl 1 wk. dose serum T4, FT4, TSH
2 & 4 wk.
- F/U
Age 1 yr. q 1-2 mo.
Age 2-3 yr. q 2-3 mo.
 TOP SI 117

Age > 3 yr. q 3-12 mo.

- 1 & 5 yr. development Psychometric test severe,
treat low-normal IQ, , , fine motor coordination
Hyperthyroidism
- hyperthyroid anti-thyroid drug MTZ major SE ,
OD/bid ( PTU tid)
- Pregnancy anti-thyroid drug PTU ( MTZ, I-131, Sx)
- I-131 ( anti-thyroid drug 1-2 wk. + pregnancy test ) high-
dose I-131 Graves' prone malignancy ( hypothyroid
)
- Thyroidectomy thyroid Total thyroidectomy (
subtotal ) hypothyroid
Calcium disorders
Hypocalcemia
- Ca2+ 4 cc/kg/d
Pituitary diseases
Diabetes insipidus (DI)
- Polyuria = Urine output 2,000 cc/m2/d
- NeuroSx SIADH, DI, etc.
Diabetes mellitus (DM)
- DM criteria Dx American Diabetes Association (ADA)
1. Symptoms of DM (Polyuria, Polydipsia, Unexplained weight loss) + CPG 200 mg/dl
2. FPG 126 mg/dl (x2 symptoms)
3. 2-hr PG in OGTT 200 mg/dl
4. HbA1C 6.5%
- OGTT glucose 1.75 g/kg (kg ideal BW)
- FPG < 100 mg/dl, 2-hr PG < 140 mg/dl
- FPG 100 mg/dl < 126 mg/dl Impaired fasting glucose (IFG)
- 2-hr PG 140 mg/dl < 200 mg/dl Impaired glucose tolerance (IGT)
- DM type 1 Multifactorial: Gene , Infection (Mumps, Rubella, Coxackie),
, Chemical toxin Ag -cell Ab -cell ( Insulitis)
- Investigation: Anti-GAD, IA2
- DM type 2 Genetic factor
1.
2. Diet: Simple sugar, Fat metabolite Mitochondria muscle cell, fat cell
 TOP SI 117

3. Exercise
Insulin resistance Chronic hyperglycemia (insulin , -cell
insulin insulin ) liver detect insulin Gluconeogenesis
Blood sugar
- DM type 2 PE: Acanthosis nigricans ( Insulin resistance)
- Complications (DR, DN) q 1 yr.
DM type 1 : Dx 2 ; : Dx 5
DM type 2 Dx
- complication insulin: Lipohypertrophy, Lipoatrophy
- DN FSGS (Focal segmental glomerulosclerosis) Nephrotic syndrome
Diabetes ketoacidosis (DKA)
- DKA DM type 1; criteria Dx 3
1. Hyperglycemia: Plasma glucose > 200 mg/dl
2. Acidosis: HCO3- < 15 mmol/l or Venous pH < 7.3
3. Urine / Serum ketone +ve
- Severity HCO3- & Venous pH
HCO3- Venous pH
Mild < 15 < 7.3
Moderate < 10 < 7.2
Severe <5 < 7.1
- S&S: Dehydration, , N/V, Abdominal pain, , acetone , Kussmaul breathing (
acidosis)
- Pathophysiology: insulin ( blood sugar), lipolysis ( ketone) +
Precipitating cause Counter-regulatory hormone blood sugar (
Glycogenolysis + Gluconeogenesis) Hyperosmolarity Osmotic dieresis & Electrolyte
Dehydration
- Precipitating factors
1. Stress Infection, Shock
2. Poor compliance Insulin
3. Drug blood sugar
- Management: volume depletion, drip RI, add K+
1. IV fluid ( + = + +
100
100
1.6)
DKA Dehydration
- Fluid = Maintenance + Deficit (Moderate 5-7%, Severe 7-10%) 48 hr.
- 4-6 hr. NSS, then N/2
- Shock Load NSS 10-20 cc/kg in 1 hr.
 TOP SI 117

- rate 24 hr. 2 Maintenance Cerebral edema

2. Insulin
- Drip RI initial rehydration 1-2 hr., RI 0.1 U/kg/hr IV drip
- monitor plasma glucose < 250-300 mg/dl > 100 mg/dl /hr
5%D/N/2, keep plasma glucose 150-250 mg/dl
RI IM q 1 hr.
+ +
3. K (K Osmotic diuresis, Vomiting, 2 Hyperaldosteronism dehydration)
- initial rehydration & urine
- K+ < 3.5 add K+ 40-60 mEq IV 1 L
- K+ 3.5-5.5 add K+ 30-40 mEq IV 1 L (maintain K+ ~ 3.5)
- K+ < 5.5 K+
4. HCO3-
1) Severe shock
2) pH < 7.3
3) Life-threatening hyperK+
5. PO4 ; K2HPO4 + KCl 1:1
6. Monitor V/S, I/O, Neurological sign, Blood sugar q 1 hr.
7. Urine ketone q 2 hr. ve 2
8. Electrolyte q 2-4 hr., BUN/Cr, Ca2+, Mg2+, PO4, ABG
9. Correct precipitating cause
10. Prevent & correct complications Hypoglycemia, Persistent acidosis, HypoK+, HypoCa2+, Cerebral
edema
11. Long-term treatment of DM after recovery from DKA Oral hypoglycemic drugs / Insulin
Hyperglycemic hyperosmolar state (HHS)
- HHS DM type 2; common DM hyperglycemia;
criteria Dx 5
1. Plasma glucose > 600 mg/dl
2. Arterial pH > 7.3
3. Serum HCO3- > 15
4. Urine ketone ve
5. Effective serum osmolarity > 320 mOsm/kg
Effective serum osmolarity = 2Na+ + Glucose/18
- HHS gradual onset, Neuro (stupor, unconscious, seizure, chorea), CVD
Adrenal insufficiency
Adrenal crisis
- Chronic adrenal insufficiency Stress (e.g. Infection, Sx)
 TOP SI 117

- S&S: High fever, Dehydration, N/V, Hypotension / Shock

- Adrenal crisis
1. Ambiguous genitalia CAH ( FTT, Hyperpigmentation, Hypotension)
2. Midline defect Cleft lip / Cleft palate, Holoprosencephaly ( Hypopituitarism)
3. Hx of Adrenal gland disease + Stress (e.g. Infection, Sx)
4. Withdrawal from Steroid therapy
- Dx Serum cortisol Steroid
- severe stress Serum cortisol > 20 g/dl
Adrenal insufficiency Serum cortisol < 20 g/dl
- Confirm Dx
1. 1 Adrenal insufficiency Standard (250 g) ACTH stimulation test
2. 2 Adrenal insufficiency 1 g ACTH stimulation test Insulin intolerance test
- Adrenal crisis Lab. ( cortisol )
- Hypoglycemia
- HypoNa+, HyperK+, HyperCa2+, Metabolic acidosis, Urine Na+
- CAH: Serum Testosterone, Progesterone, 17-0H Progesterone
- Management for Adrenal crisis at ER
1. Glucocorticoid replacement: Hydrocortisone
Initial dose: 50-100 mg/m2 IV push / IM (: 25 mg, : 50 mg, : 100-150 mg)
Then 100 mg/m2/d IV drip continuous or IV q 6 hr. or IM
2. Fluid replacement: add 10% Deficit
- Shock NSS 10-20 cc/kg IV in 15-30 min, then 5%D/NSS ( HypoNa+
salt wasting 5%D/N/2 5%D/N/3 )
3. HypoNa+: Maintenance 2-3 mEq/d, Na+ deficit = (135 ) x BW x 0.6
10 mmol/L/d Central pontine myelinolysis (CPM)
4. Hyperglycemia: 10% Dextrose 2 cc/kg (Glucose 0.2-0.5 g/kg), keep blood sugar 70-150 mg/dl
5. HyperK+: Monitor EKG
- K+ > 6 Kayexalate 1 mg/kg PO / enema
- K+ > 7 NaHCO3 1-2 mEq/kg IV RI + Dextrose
- Abnormal EKG (peaked T, prolonged PR, Bradycardia, disappear P wave, wide QRS)
10% Ca gluconate 0.5-1 cc/kg in 10 min
- Long-term management for Adrenal insufficiency
1. Glucocorticoid replacement: Hydrocortisone 8-10 mg/m2/d bid/tid (Physiologic dose:
Cortisol 10-20 mg/m2/d) = Cortef 2-3 /d ( Prednisolone 1-2 /d)
Stress (e.g. Infection) dose 3 Physiologic 30-50 mg/m2/d
2. Mineralocorticoid replacement: Fludrocortisone 0.05-0.2 mg/d ( SE:
Hypotension, HypoK+), NaCl tab 2-4 g/d supplement
 TOP SI 117

Pediatric obesity
- Weight for height (%W/H)
%W/H > 120% Overweight
%W/H > 140% Obesity
%W/H > 200% Morbid obesity
- Approach:
1. Obesity: %W/A > P97 %W/H > 140%
2. Normal Ht. velocity, Normal or higher Ht. percentile Simple obesity ()
Decreased Ht. velocity, Ht. below mid-parental Pathological obesity ()
- Metabolic syndrome criteria Dx (IDF 2006)
1. Waist circumference > P90
2. 2/4
1) TG > 150 mg/dl (or on treatment)
2) HDL < 40 mg/dl (male), < 50 mg/dl (female) (or on treatment)
3) BP > 130/85 mmHg (or on treatment of HT)
4) FPG > 100 mg/dl (or Pervious Dx DM type 2) criteria OGTT
- Investigation: FBS OGTT, Lipid profile, U/A, LFT ( NAFLD: ALT, AST:ALT < 1)
- Lipid profile
1. TC 170 200 (< 170 Normal; 170-199 Borderline; 200 Hypercholesteralemia)
2. TG 150 200 (< 150 Normal; 150-199 Borderline; 200 Hypertriglyceridemia)
3. LDL 110 120 (< 110 Normal; 110-120 Borderline; 120 High LDL)
4. HDL 40 ( 40 Desirable; < 40 Undesirable)
- Thick skin fold > P85 age & sex
- BMI obesity > P95 age & sex
- Waist circumference obesity > 90 cm (male), > 80 cm (female)
- OSA obesity CBC Polycythemia (Hct) hypoxia
- Pickwikian syndrome (Obesity hypoventilation syndrome, OHS) -
hypoxemia & hypercapnia & hypoventilation, lung volume
complications Polycythemia, PHT, Rt.-sided HF
- Puberty obesity onset of puberty fat tissue Estrogen
Tanner stage ( Genitalia & Breast )
- PCOS obesity ( obesity insulin resistance Reproductive system
); criteria Dx ( 2/3 )
1. Oligomenorrhea / Anovulation
2. Clinical and/or Biochemical signs of Hyperandrogenism , (Hirsutism),
3. Polycystic ovaries ( U/S)
 TOP SI 117

exclude (CAH, Androgen-secreting tumor, Cushing syndrome)

- Slipped capital femoral epiphysis (SCFE) proximal epiphysis femur epiphyseal plate
inferior & posterior; esp. growth spurt
- Blounts disease proximal tibia BW = Tibia vara (Bowed legs)
- Management: Lifestyle modification (LSM)
1. Diet: Nutritionally balanced diet, protein 1.5-2 g/kg
- Age 2-6 yr.
BMI P85-94 & BMI P95 but no complication Maintain weight
BMI P95 with complication Lose weight
( Lose weight BMI P95 with complication)
- Age 7 yr.
BMI P85-94 but no complication Maintain weight
BMI P85-94 with complication & BMI P95 Lose weight
( Lose weight BMI P85-94 with complication)
- Diet Lose weight:
Start: Hypocaloric diet (1,200 kcal/d) 2 wk.
Then Protein-sparing modified fast (PSMF) (600-800 kcal/d) 12 wk.
Then Hypocaloric diet (1,200 kcal/d) ()
- , , , ,
, /
2. Exercise: TV, 30 min 5 d/wk.,
,
3. Behavioral modification: TV ( 1-2 hr/d), remote control, TV / games

 TOP SI 117

Infectious Diseases
Sepsis
- Signs of sepsis: , Hypo/Hyperthermia, Hypo/Hyperglycemia, Food intolerance
- Gram positive sepsis ATB treat 7-14 d
Gram negative sepsis ATB treat 14-21 d
- : T peripheral central ( chill )
Septic shock
- Management
1. Load NSS 20 cc/kg in 15-30 min ()
2. BP Load 3 doses ( 60 cc/kg) Load
1 hr.
3. BP Inotrope
Antibiotics
- S. pneumoniae : binding protein dose
H. influenzae, M. catarrhalis : -lactamase BL-BI
- Actinomyces israelii ATB: PGS
Nocardia asteroids ( immunocompromised) ATB: Bactrim (Co-trimoxazole)
- Meropenem E. faecalis E. faecium, Stenotrophomonas maltophilia
- Tigecycline P. aeruginosa, A. baumannii colistin
- Caspofungin Cryptococcus
Pharyngitis
- Exudative pharyngitis DDx 4
1. GAS infection
2. Infectious mononucleosis (IMN)
3. Fungal infection (Candida)
4. Diphtheria
- < 3 yr. IMN ( GAS)
> 3 yr. GAS IMN ( triad IMN, Downey cell)
treat GAS ( RF, APSGN) IMN rash Ampicillin
Amoxicillin
- DPT vaccine 3 doses diphtheria
Streptococcus group A (S. pyogenes, GAS) infection
- Non-suppurative complication GAS
1. Rheumatic fever (RF) Pharyngitis
 TOP SI 117

2. Acute post-streptococcal glomerulonephritis (APSGN) Pharyngitis & Ecthyma

GAS Pharyngitis RF & APSGN
GAS Ecthyma APSGN
- Suppurative complication GAS
1. Otitis media
2. Sinusitis
3. Peritonsillar abscess (PTA, Quinsy)
4. Retropharyngeal abscess (RPA)
5. Suppurative cervical adenitis
- Investigation
1. Rapid detection for Streptococcal Ag
2. Throat swab for C/S (Sheep-blood agar)
3. CBC, PBS
- Management: GAS infection treat complication
1. Penicillin V 250 mg tid x 10 d
Penicillin Erythromycin 40 MKD 2-4 /d x 10 d
2. Paracetamol
3. Advice: , (), soft diet
- ATB 9 d onset infection prevent Non-suppurative complication (
Suppurative complication )
Retropharyngeal abscess (RPA)
- RPA ( LN ), complication Pharyngitis
- GAS, S. aureus
- S&S:
- Muffled voice, Stridor
- Hyperextension , Stiff neck Torticollis ( irritate Paravertebral m.)
- Dysphagia, Drooling ( )
- Unilateral bulging posterior pharyngeal wall ()
- Fluctuation ( Trendelenberg position: & suction
abscess rupture )
- DDx: Croup, Epiglottitis ( ), Meningitis, TB C-spine
- Investigation: Film lateral neck (Soft tissue technique) mass at retropharyngeal area
- Management
1. Paracetamol
2. IV fluid ()
 TOP SI 117

3. Fluctuation Cloxacillin 100-150 MKD 4 Penicillin 100,000-250,000 UKD

()
4. Fluctuation I&D under GA
Herpes virus infection
- Human herpes virus (HHV)
Infectious mononucleosis (IMN, Glandular fever)
- EBV (HHV 4) infection; triad
1. Exudative pharyngitis
2. Lymphadenopathy
3. Hepatosplenomegaly
- Virus IMN, IMN-like 5 CHETA CMV, HAV, EBV, Toxoplasma, Adenovirus
- IMN Puffy eyelid = Hoaglands sign (bilateral lid swelling)
- CBC: Leukocytosis, Atypical lymphocyte
PBS: Downey cell ( atypical lymphocyte IMN cytoplasm
RBC, RBC )
- Management: Supportive
- Steroid IMN I/C
1. Upper airway obstruction (UAO) / Severe tonsillar hypertrophy (prevent UAO)
2. Impending respiratory failure
3. Liver failure
4. Hematologic complication: AIHA, Severe thrombocytopenia
5. Severe malaise and fever
6. Severe CNS / Cardiac diseases
Herpangina
- Coxackie virus, Echovirus ( 2 Enterovirus)
- Symptom:
D.1
D.2
D.3
- : , , , conjunctivitis
- PE: Multiple oral vesicles 1-2 mm at Soft palate & Posterior pharyngeal wall D.2-3
spontaneous rupture ulcer, Cervical lymphadenopathy
- 5-7 d, complications
- DDx: Hand-foot-mouth disease ( EV-71; lesion & ), Herpetic gingivostomatitis (
buccal mucosa soft palate)
- Management
 TOP SI 117

1. : Paracetamol 10-15 MKD prn,

2. : , Xylocaine viscus
Tuberculosis
- Hx , , , ,
- Investigation: CXR TB (e.g. mass)
1. PPD (Tuberculin skin test, TST)
Treat PPD +ve 10 mm (Normal host), 5 mm (Immunocompromised host)
2. Sputum AFB ( sputum ), Gastric wash AFB
3. PCR
4. Biopsy ( Pathology)
5. CXR
- Management: Anti-TB drugs: 2HRZE(S)/4HR 2HRZ/4HR ( E); OD 6 mo.
Dosage
Isoniazid (H) 10-20 MKD OD (Max = 300 mg/d); SE: Confusion, Peripheral neuritis, Increased
metabolism of vitamin B6, Hepatitis, Rash, Hypersensitivity reaction
Rifampicin (R) 10-20 MKD OD (Max = 600 mg/d); SE: Hepatitis, Rash, GI symptom, Abnormal LFT, Red
urine/sputum/tears/soft contact lens (Red man syndrome)
Pyrazinamide (Z) 20-40 MKD OD/bid (Max = 2 g/d); SE: Hepatitis, Anorexia, N/V, Rash, ,
, Sideroblastic anemia
Ethambutol (E) 15-25 MKD OD (Max = 2.5 g/d); SE: Optic neuritis, Red-green color blindness,
Hyperuricemia
( < 12 yr. Ethambutol SE )
Streptomycin (S) 20-30 MKD IM; SE: Ototoxicity, Nephrotoxicity,
Dengue infection
- DF (Dengue fever)
Probable case: + 2
1.
2.
3. / (Breakbone fever)
4.
5. (Touniquet test +ve, Petechiae, Epistaxis)
6. WBC 5,000
Confirmed case: isolation, titer
- DHF (Dengue hemorrhagic fever) criteria
1. Fever 2-7 days ( > 38.5C)
2. Hemorrhagic tendency (, Touniquet test +ve)
 TOP SI 117

3. Thrombocytopenia (Plt < 100,000) DHF

4. Plasma leakage (Hct 20% age (< 2 yr.: 30%; 2-10 yr.: 35%; > 10 yr.: 40%); Pleural
effusion, Ascites, HypoNa+) DHF
- menses DHF menses
- Paracetamol NSAIDs DHF
- DSS (Dengue shock syndrome) = DHF + Pulse , PP ( 20 mmHg) / Hypotension

- Refer DHF I/C
1. Age < 1 yr.
2. U/D (G6PD, Thalassemia, Heart disease)
3. Massive bleeding
4. Unusual manifestation
5. Gr. 3, 4
6. //
HIV infection
- Perinatal HIV infection 90% ; 2/3 , 1/3
- Risk factor: Viral load , Chorioamnionitis, Preterm, PROM, Breastfeeding
- Thai PMTCT guidelines 2010
1. ANC Anti-HIV +ve CD4 count
CD 4 < 350
- AZT 1 tab + 3TC 1 tab + LPV/r 2 tab q 12 hr.;
( SE LPV/r EFV )
- labor pain AZT q 3 hr.
- Adult (HAART regimen)
- AZT 4 mg/kg q 12 hr. x 4 wk.
CD4 > 350
- GA 14 wk.
- labor pain AZT q 3 hr.
- ARV ; EFV ( T1/2 ) AZT + 3TC 1 wk.
- AZT 4 mg/kg q 12 hr. x 4 wk.
ARV AZT (), EFV
off 1st trimester ( off abortion)
2. No ANC Labor pain
- : AZT q 3 hr. () NVP 1 tab 1 dose ( 2 hr.
), Zilavir 1 wk.
- : 48 hr.: NVP syrup 2 mg/kg q 24 hr. x 7d, then 4 mg/kg q 24 hr. x 7d
+ AZT syrup 4 mg/kg/dose q 12 hr. x 4 wk.
 TOP SI 117

+ 3TC syrup 2 mg/kg/dose q 12 hr. x 4 wk.

(: NVP 2 wk., AZT + 3TC 4 wk.)
- HIV infection
1. Dx clinical
2. Screening: PCR: HIV DNA, HIV RNA 2 1-2 mo., 2-4 mo.
+ve 2 HIV infection
-ve 2 1mo. & 4 mo. HIV uninfected
3. Confirm: Anti-HIV 12 mo. & 18 mo.
+ve 18 mo. HIV ( +ve )
- Opportunistic infection
PCP: Co-trimoxazole 150/750 mg/m2/d OD 4-6 wk. 6 mo.; ;
HIV 1 yr.
TB: Hx contact TB PPD & CXR; Hx contact TB INH 10-15 MKD OD 9 mo.
- CDC pediatric HIV classification (for children < 13 yr.)
Clinical
N: Asymptomatic
A: Mildly symptomatic Lymphadenopathy, Hepatomegaly, Splenomegaly, Dermatitis, Parotitis,
Recurrent UTI
B: Moderately symptomatic Lymphoid interstitial pneumonia (LIP)
C: Severely symptomatic
Immunological
1 = Normal, 2 = Moderate suppression, 3 = Severe suppression
- HIV 1st line: AZT + 3TC + NVP ( NVP 1-3 yr., > 3 yr. EFV )
Age < 1 yr. Treat
Age 1-5 yr. Treat CD4 < 25%
Age > 5 yr. Treat CD4 < 350/mm3
Vaccination for Thai children
- EPI Vaccination for Thai children
1. BCG (ID)
- Lt. shoulder Newborn
- TB meningitis
- Indurated papule/Small abscess 2-3 wk. after BCG, Regional lymphadenopathy
(axillary); immunocompromised Disseminated BCGosis
- alcohol
- complication severe INH 4-6 wk.
2. HBV (IM)
- 3 0, 2, 6 mo. HBV carrier 0, 1, 6 mo.
 TOP SI 117

- Safe, Efficacy 90-95%

- 3-4 hr. ,
- HBV carrier (HbsAg +ve) HBIG (passive
immunization) & 3 ( vaccine
9 mo. MMR)
- Preterm BW < 2 kg response vaccine
- HBV carrier ( no ANC) 1
, then 3 0, 1, 6 mo. term 4
- carrier 1 mo. D/C
- 4% True non-responder (Ab protective level) Re-immunize 3
( 0, 1, 6 mo. )
3. DTPw (IM)
- 5 2, 4, 6 mo., 1 yr., 4-6 yr.
- Fever, Febrile convulsion, Hypotonic hyporesponsive episode (HHE), Encephalopathy,
3 hr. ( 2 )
- = Arthus reaction tetanus toxoid immune
- reaction ( complication )
- dT booster q 10 yr.
4. OPV
- 5 DTPw ( 2-3 )
- OPV 3 Excellent sustained Ab & gut immunity (probably lifelong)
- vaccine live-attenuated active VAPP (Vaccine associated
paralytic poliomyelitis)
- C/I:
1. Immunocompromised host ( HIV)
2. Pregnancy
3. Anaphylactic reaction ( Neomycin, Streptomycin, Polymyxin B)
- Immunocompromised/ CMT
- OPV Polio AFP (acute flaccid paralysis)
- < 5 yr. AFP 506 + stool 2
- IPV Polio-free
5. MMR (SC)
- 2 9 mo., 4-6 yr. ( DTPw5 & OPV5)
- Efficacy Measles & Rubella (95%) Mumps
( Jeryl-Lynn; Efficacy 60-80%)
- SSPE (Subacute sclerosing panencephalitis)
- / 1 wk. (), Thrombocytopenia 2 mo.
 TOP SI 117

- 20 min
- C/I:
1. Immunocompromised host
2. MMR
3. Pregnancy ( 1 mo. )
4. IG
- Anti-TB start MMR
- PPD MMR , PPD MMR MMR
PPD 4-6 wk. MMR
6. JE (SC)
- 3 1 yr. 2 1-4 wk., 3 2 yr.
12 mo.
(Killed JE 3 Live attenuated JE 2 3 mo.)
- Booster 3-5 yr. ( 5 doses)
- Hypersensitivity reaction (Generalized urticaria, Angioedema) (rare)
- C/I:
1. Pregnancy
2. < 1 yr.
3. Adverse reaction JE vaccine
Vaccine
Newborn BCG, HBV1
2 mo. HBV2, DTPw1, OPV1
4 mo. DTPw2, OPV2
6 mo. HBV3, DTPw3, OPV3
9 mo. MMR1
1 yr. JE1, JE2 ( 1 wk.)
1 yr. DTPw4, OPV4
2 yr. JE3
4-6 yr. DTPw5, OPV5, MMR2
12-16 yr. dT (booster q 10 yr.)
- Vaccine
- VZV 2 1 yr., 4-6 yr.
- HAV 2 1 yr., 1 yr.
- Rabies
- vaccine HRIG + HDCV (Rabies
vaccine; IM) 5 D.0, 3, 7, 14, 28 Deltoid/Anterolateral thigh
- vaccine ( HRIG) HDCV 2 D.0, 3
 TOP SI 117

- vaccine Pre-exposure prophylaxis (PEP) Veterinarian, Virology lab personnel

3 D.1, 7, 21-28)
 TOP SI 117

Dermatology
-
(e.g. Candida) Nystatin, Clotrimazole
- Diaper dermatitis VS Candida dermatitis ( well-defined erythematous patch )
Diaper dermatitis: Spare inguinal region
Candida dermatitis: spare
- SSSS (Staphylococcal scalded skin syndrome): Generalized desquamation, Erythroderma;
Nikolsky sign positive (); crusting ,
, = Sunburst appearance
- SSSS VS TEN
SSSS: involve mucosa
TEN: Involve mucosa
Streptococcus group A (S. pyogenes, GAS) infection
Scarlet fever
- Scarlet fever () PE: Fine, sandpaper-like rash, Circumoral pallor, Strawberry tongue
Eczema
- 3 acute, subacute, chronic
- Loratadine 10 mg OD (, )
Acute eczema
- PE: Vesicle, Serum oozing,
- Acute eczema lesion : lesion Wet dressing (Wet compression)
Subacute eczema
- PE: Scale, Crust, lichenification
- Management: 0.1% 0.02% TA cream ( inflammatory process)
Chronic eczema (Lichen simplex chronicus)
- PE: Lichenification ( + + increased skin marking), Hyperpigmentation, Excoriation ()
Atopic dermatitis (AD)
- AD chronic; Allergic march;
Allergic march: age of onset
( 4 )
1. Food allergy
2. Atopic dermatitis (AD)
3. Asthma
4. Allergic rhinitis (AR)
 TOP SI 117

- Onset: 80-90% 2 yr., > 90% 5 yr.

- Typical distribution
Infantile AD , Extensor -
Childhood AD & Adult AD Flexor, (Antecubital), (Popliteal),
(Groin & Axilla AD common Seborrheic dermatitis)
- Dx AD Hanifin & Rajkas criteria 3/4 major criteria + 3 minor criteria
Major criteria
1. Pruritus
2. Typical morphology & distribution
3. Chronic dermatitis / Chronically-relapsing dermatitis
4. Personal Hx or FHx of Atopy (Asthma, AR, AD)
Minor criteria
1. Xerosis
2. Ichthyosis () / Palmar hyperlinearity () / Keratosis pilaris (=
kink )
3. Immediate (type 1) skin test reactivity
4. Elevated serum IgE
5. Early age of onset
6. Tendency toward cutaneous infection (S. aureus, HSV) / Impaired CMI
7. Tendency toward non-specific hand or foot dermatitis
8. Nipple eczema
9. Cheilitis
10. Recurrent conjunctivitis
11. Dennie-Morgan infraorbital fold (skin crease ;
develop Allergic shiner)
12. Keratoconus
13. Anterior subcapsular cataract (ASC)
14. Orbital darkening = Allergic shiner
15. Facial pallor / erythema
16. Pityriasis alba (= ; )
17. Anterior neck folds
18. Itch when sweating
19. Intolerance to wool and lipid solvents
20. Perifollicular accentuation ( hair follicle goose bumps)
21. Food intolerance
22. Course influenced by environment / emotional factors
23. White dermographism / Delayed blanch
 TOP SI 117

- - = Nummular eczema AD
- Pityriasis alba I/C Hx
- AD abrasion 2 bacterial infection Abscess
Tendency toward cutaneous infection minor criteria AD
- Management
1. Hydration of skin ( AD lesion )
- /
- Lotion cream / Ointment;
( cream Fragrant-free / )
- ( )
- ( 1) , 2) occlude moisturizer
; moisturizer natural moisturizer
)
2. Topical steroid inflammation, potency , SE steroid
3. Antihistamine (AH) ( 2 bacterial infection)
Oral ( 1st Gen.
2nd Gen. 3rd Gen. )
IV
Topical AH () Desensitization ()
4. ATB 2 bacterial infection fungal infection
5. Avoid aggravating factors
Specific , infant food allergy
( hypoallergenic food
; severe food allergy e.g.
, food allergy sequence Allergic march)
Non-specific , , emotional stress ,
, cotton
- Education: , , Psychosupport
- Prognosis
- prognosis ( 2 yr., 5 yr.)
- & Adult chronic
- Severe AD control steroid Topical immunosuppressant
Topical calcineurin inhibitor (e.g. Tacrolimus, Pimecrolimus (Elidel), Cyclosporine), MTX, MMF
2nd line severe, control topical treatment
( 1st line FN )
 TOP SI 117

- AD severe adult defect Filaggrin gene (Filaggrin protein matrix

keratin fibers epithelial cells skin) TEWL (Transepidermal water loss)
dermatitis
Management: 1 ~ 1 hr. ,
Seborrheic dermatitis
- Seborrheic dermatitis (Seb derm) Typical distribution: Scalp, , , Nasolabial fold, Retroauricular
(), Groin, Axilla, Interscapular, Sternum, ( sebaceous gland
; T-zone )
Nummular eczema
- Nummular eczema -
- Management: Symptomatic ;
Infectious eczematoid dermatitis
- Infectious eczematoid dermatitis infection organ (e.g. Otitis media with perforation,
Rhinitis, Vaginitis) discharge contact dermatitis orifice
infection superimposed
- Management: Wet dressing + Treat 1 infection; treat infection apply Steroid
 TOP SI 117

Hematology
- Peripheral blood smear (PBS)
Zone : RBC
Zone : RBC e.g. Polychromasia (Reticulocyte), NRC
- Physiologic anemia of infancy NCNC 2-3 mo. (term) 7 wk. (preterm)
- Parvovirus B19 = Fifth disease (Erythema infectiosum, Slapped cheek syndrome)
infect Young RBC BM Red cell aplasia
Microcytic anemia
Iron deficiency anemia
- Fe
1 d Clinical
1 wk. Reti. count
1 mo. Hb
Thalassemia
- present thalassemia > 6
- RDW CBC anisocytosis
- Hypersplenism = spleen CBC RBC, WBC, Platelet
splenectomy
Thalassemia splenomegaly ( RBC )
hypersplenism
- Splenectomy I/C Pneumococcal polysaccharide vaccine (23 serotypes)
Penicillin V prophylaxis
- CBC: Hct Hb (Hct:Hb = 4 ), MCV 60 fl HbH disease
- CBC: Target cell 3+ Homozygous HbE
- HbH disease Acid elusion test
= RBC HbH
Hemolytic anemia
- PBS Schistocyte hemolysis
- Hemolysis ABO/Rh incompatibility, G6PD, HS, TORCH infection, etc.
- Hemolysis AST ( AST RBC Liver ALT )
- Hemolysis general management
1. Hydration
2. Alkalinize urine
Hereditary spherocytosis (HS)
 TOP SI 117

- HS (Hereditary spherocytosis) AD ( new mutation) fatigue, pallor, jaundice

AD / spherocyte
- HS Osmotic fragility test : hypotonic saline (
Thalassemia)
G-6-PD deficiency
- Blood smear RBC with contracted Hb, Hb leakage, bite cell, ghost cell, anisocytosis, poikilocytosis,
spherocytosis, polychromasia
- methylene blue bromocresyl green Heinz body
Bleeding disorders
Primary immune thrombocytopenia (ITP)
- ITP Sudden appearance of petechiae, purpura and ecchymosis; 2-10 yr. (peak
2-5 yr.)
- ITP criteria; Dx by exclusion; S&S Mucocutaneous bleeding; splenomegaly
- Hx Bleeding symptom, Viral infection, Post-vaccination, Symptoms of autoimmune, Risk factor
for HIV, Medication (Heparin, Quinine, Sulfa, ASA), FHx
- Investigation
1. CBC: Hb & Hct ( blood loss), Platelet ( < 50,000/mm3)
2. BMA: Megakaryocyte with young form, Erythroid hyperplasia ( blood loss)
- Management: Supportive 80-90% 3 mo.
6 mo. thrombocytopenia = Chronic ITP
- treat Platelet < 30,000/mm3; High-risk hemorrhage treat Platelet < 50,000/mm3
Admit Platelet < 10,000/mm3
Goal: Platelet > 30,000/mm3 ( severe bleeding normal population)
: Prednisolone 2 MKD 3-4 wk. F/U: platelet goal tape off 2 wk.
treat 6 wk. ( response 1-3 wk.) Steroid resistance hematologist
- Platelet 1-2 severe bleeding Elective splenectomy ( > 4
yr. ); Sx 2/3
Von Willebrand disease (vWD)
- VWD present Bruise, Mucosal bleeding, Hypermenorrhea
- prolonged aPTT ( F8 deficiency )
- 3 types
1. Type 1: most common, AD
2. Type 2: AD
3. Type 3: most severe, rare, AR, vWF 1%, marked deficiency F8
Hemarthrosis ( hemophilia)
 TOP SI 117

Hemophilia
- Prolonged aPTT
- XR (); 80% Hemophilia A ( F8), 20% Hemophilia B ( F9)
- S&S Hemarthrosis (esp. knee jt.), Hematoma (intramuscular, retroperitoneal), Bruise, Mucosal
bleeding (GI (e.g. bleeding per gum), GU), Intracranial bleeding
Hemophilia C ( F11) mild bleeding
hemarthrosis misleading term Hemophilia C Factor
11 deficiency
- Severity
Normal factor activity
Mild 5-25%
Moderate 1-5%
Severe < 1%
- keep 30-60% 2-3 d
life-threatening (intracranial bleeding) keep 100% 1 wk.
- FFP factor; Cryoprecipitate factor 1, 8, 13, vWF
hemophilia A cryoprecipitate, hemophilia B FFP
hemophilia FFP
- F8
- 1 U/kg F8 2%, q 12 hr. ( T1/2)
- FFP 1 cc F8 1 U
- Cryoprecipitate 1 bag (1 U) F8 100 U
- F9
- 1 U/kg F9 1%, q 24 hr. ( T1/2)
- FFP 1 cc F9 1 U
Example:
1. 10 kg hemophilia A intracranial bleeding ?
: 100% F8 50 U/kg = 500 U cryoprecipitate 5 bag 12 hr.
2.5 bag 1 wk. #
2. 10 kg hemophilia () intracranial bleeding ?
: 100% F8 & F9
F9 100% F9 100 U/kg = 1,000 U FFP 1,000 cc
F8 100% F8 50 U/kg = 500 U FFP 500 cc
FFP 1,000 cc stat 12 hr. 500 cc #
- prolonged VCT Severe coagulation defect (coagulation factor < 1%)
- DDAVP (Minirin) = ADH
1. IV Mild hemophilia A F8 clotting activity
 TOP SI 117

2. Nasal spray (absorb Cribiform plate) DI brain

Hematologic malignancies
- LN
: > 0.5 cm
: > 1 cm
- LN Biopsy
1. Hx & PE suggest malignancy
2. Size > 2.5 cm
3. LN persists / enlarges ( / )
4. Fail ATB after 2 wk.
- lab TLS
- hematology (e.g. leukemia, lymphoma) = Relapse
( solid tumor Recurrent)
- MTX (Methotrexate) SE: Interstitial pneumonitis, Hepatic portal fibrosis, Leukoencephalopathy (
permanent damage), Mucositis / IV
hydration MTX
SE CMT, IV hydration complications IV hydration
MTX Leucovorin SE ( Cyclophosphamide Mesna)
- CMT BM suppression: ABCD
1. L-Asparaginase
2. Bleomycin
3. VinCristine
4. Dexamethasone/Prednisolone
- Cisplatin SE: Peripheral nephropathy, Nephrotoxicity, Hypophosphatemia
clinical Hypophosphatemic rickets
Lymphoma
- Most common Mediastinal mass Lymphoma
- Staging: CXR, Film plain abdomen, Bone scan, BMA, LP
Stage 1
Stage 2 2
Stage 3 diaphragm
Stage 4 involve BM, brain
- CHOP regimen: Cyclophosphamide, Hydroxydaunorubicin (Adriamycin), Oncovin (Vincristine),
Prednisolone; NHL
Leukemia
-
 TOP SI 117

1. Acute leukemia AML, ALL

2. Chronic leukemia CML, CLL
- ALL B-cell ( CD19, 20) prognosis T-cell ( CD3) lymphoma

 TOP SI 117

Oncology
- Tumor Neuroblastoma ( malignant)
Tumor Wilm tumor (Nephroblastoma)
- Neuroblastoma VS Wilm tumor
Neuroblastoma Wilm tumor
Abdominal pain, Bone pain,
Symptom Symptomless
Metastasis, Pale
Consistency Firm, Irregular surface Tense cystic or firm, Smooth surface
Intra-abdominal palpable, may Bimanual palpable,
Palpable
Cross midline usually Unilateral
Calcification Common Rare
Multiple intra-abdominal
Well-circumscribed mass,
CT abdomen lymphadenopathy with
may extend to IVC
extensive organ involvement
- Tumor marker Neuroblastoma NSE (Neuron-specific enolase)
Oncologic emergencies
Febrile neutropenia (FN)
- FN criteria DX
1. T 38.5C 1 peak T 38C 2 peaks ( 1 hr.)
( Medicine 38.3C 38.5C 1 peak)
2. ANC < 500 ANC < 1,000 with predicted nadir < 500
Tumor lysis syndrome (TLS)
- TLS electrolytes PUKCa (P, Uric acid, K; Ca)
1. Hydration e.g. 1.5M; keep Urine sp.gr. < 1.010
2. Alkalinization keep urine pH 6.5-7.5
- TLS Uric acid toxic tubule ATN (
renal failure CMT , dialysis
- TLS Burkitt's lymphoma q 6 hr.
(5 CMT) TLS hydration
 TOP SI 117

Neurology
Seizure
- Seizure = Abnormal excessive neuronal discharge
- Convulsion = Seizure involuntary contraction voluntary muscles
- Epilepsy () = Unprovoked seizure 2
- Dx & DDx of seizure seizure/epilepsy ( stereotype & rhythmic
Paroxysmal non-epileptic event) cause ( Hx, PE, Lab)
- Cause of seizure ABCDE
1. Alcohol withdrawal
2. Brain tumor
3. Cerebrovascular disease (CVD)
4. Degenerative disorder, Drugs (-lactams, INH, CsA)
5. Electrolyte imbalance
- Classification of seizure
1. Generalized seizure unconscious; metabolic disorder genetic;
1) Infantile spasm (Salaam seizure)
- < 1 yr.
- Tuberous sclerosis (TS) common cause ( Hypopigmented macule;
Retinal patch fundoscopy)
-
(1) Suddenly flex arms, forward flex trunk, extend legs sec
(Cluster of repetitive seizure)
(2) EEG: Hypsarrhythmia
- Vigabatrin ( Visual field defect )
- ~ 5 yr. seizure type
2) Absence seizure
(1) Typical
(2) Atypical
3) Tonic seizure
4) Tonic-clonic seizure
5) Atonic seizure
6) Myoclonic seizure
2. Partial seizure (PS) conscious ; structural abnormality;
1) Simple PS conscious
2) Complex PS conscious complete
- PS 1) Aura, 2) Todd's paralysis
 TOP SI 117

- PS turn Generalized = 2 Generalization ( loss of consciousness)

- Investigation seizure: TELEN
1) Toxicology Substance/drug abuse
2) EEG , predict recurrence unprovoked seizure
EEG recurrence )
Dx seizure/epilepsy EEG EEG , EEG
50% Hx
3) LP CNS infection Meningeal irritation, Alteration of consciousness
4) Electrolyte, Ca, Mg, PO4 Vomiting, Diarrhea, Dehydration,
5) Neuroimaging
MRI Dx lesion / Cortical dysplasia
CT emergency (e.g. Todd's paralysis / )
- I/C for Neuroimaging
1. Partial seizure
2. Unexplained delayed development
3. Abnormal neurological examination
4. Age < 1 yr.
- Valium (Diazepam) IV 0.3 mg/kg/dose rectal 0.5 mg/kg/dose
(Valium 1 cc = 5 mg; 1 amp 2 cc = 10 mg)
- Dilantin (Phenytoin) 20 mg/kg 3D: Dilantin Dextrose ( D/W
) & Delay () drip rate 1 mg/kg/min
- Phenobarbital (PNB) 20 mg/kg
- AED
1. Valium IV 2 doses
2. Dilantin ( NSS; Dextrose)
( 3 : 20-10-10 mg/kg)
3. PNB ( Dextrose ) ; tube PNB apnea
( 20 mg/kg 10 mg/kg 10 min)
Neonatal seizure PNB 1 ( Valium
albumin IB free form BBB
Kernicterus permanent damage )
Epileptic syndrome
- Epileptic syndrome
1. West syndrome (WS)
- Age < 1 yr. (2-8 mo.)
- Triad: 1) Infantile spasm, 2) Delayed development, 3) EEG: Hypsarrhythmia
- (cluster)
 TOP SI 117

- seizure
- 85% Remote symptomatic
- Congenital brain malformation
- Hypoxic ischemic encephalopathy (HIE)
- Tuberous sclerosis (TS)
- Metabolic
- 15% Cryptogenic
- Vigabatrin
2. Benign Rolandic epilepsy (BRE, Benign childhood epilepsy with centrotemporal spike)
- Age 3-13 yr.
- PS evolving to secondarily GTC
- ()
- , ,
- EEG: Centrotemporal spike 1 side/both sides
- AED, 15 yr.
3. Lennox-Gastaut syndrome (LGS)
- Age 3-5 yr.
-
- 25% infantile spasm
- Delayed development
- EEG: Slow spike & waves
- Remote symptomatic: Congenital brain malformation, HIE, CNS infection
- Valproate ( )
4. Childhood absence epilepsy (CAE) / Juvenile absence epilepsy (JAE)
- Age 4-8 yr. (CAE) / 8-12 yr. (JAE)
- Absence seizure (CAE GTC 40%, JAE GTC 80%)
- aura, post-ictal, automatism, 5-10 s, > 10 /
- Hyperventilation test (2-3 min)
- EEG: 3 Hz Generalized spike & waves
- Valproate (1st line) / Lamotrigine (2nd line) 2 yr.
5. Juvenile myoclonic epilepsy (JME)
- Age 12-18 yr.; FHx
- Myoclonic then GTC
- (/)
- EEG: 4-6 Hz Spike & waves + Polyspike & waves
- Valproate
 TOP SI 117

Febrile seizure
- Febrile seizure = Seizure CNS infection; 3 mo.-5 yr.
2
1. Simple GTC seizure < 15 min, D.1-2 , , post-ictal
2. Complex ( definition)
1) Focal / Partial seizure
2) Ictal phase > 15 min
3) ()
- DDx 4
1. CNS infection , , PE: Tense bulging fontanelle (), Signs of
meningeal irritation
2. Metabolic disturbance Hypoglycemia, HypoNa+, HyperNa+; Hx /Vomiting/Diarrhea
3. Intoxication Salicylate, INH
4. Epilepsy AED
- Septic W/U: PE source of infection (e.g. Pharyngitis, Otitis media, CNS infection headache, stiff
neck, ), LP R/O CNS infection (esp. infant) CSF cell count, cell diff., sugar, protein, C/S.
CBC, H/C
< 18 mo. LP ( S&S )
> 18 mo. , Simple febrile seizure, PE source of infection
LP
Electrolyte, Toxicology ; EEG Simple febrile seizure
- ER , O2, Valium 0.3 mg/kg/dose (
38.9C)
- Reassure ,
, Paracetamol
W/U , 30-50%
- Simple febrile seizure AED > 5 yr.
Valium 1 mg/kg q 8 hr.
- Complex febrile seizure Epilepsy AED prophylaxis: PNB 5 MKD Valproic
acid (Depakine) 20-60 MKD; Valium prophylaxis
Sturge-Weber syndrome (SWS)
- SWS 3 types
Type 1: Port-wine stain + Brain angioma
Type 2: Port-wine stain
Type 3: Brain angioma
 TOP SI 117

- SWS type 1 Seizure / Focal neurological deficit / Intellectual disability PE Port-

wine stain
- Brain angioma SWS
1. Seizure (75-90%) 1 yr.
2. Hemiparesis (25-50%) Port-wine stain ( Brain angioma )
3. Intellectual disability (50%)
4. Glaucoma , PE: Buphthalmos
- Management: Symptomatic AED, ASA prevent Stroke, Drugs used in Glaucoma, Selective
photothermolysis Port-wine stain
Cerebral palsy (CP)
- CP Recurrent pneumonia ( aspiration) Gastrostomy with
Fundoplication ( fundus stomach LES mucous
flow )
Hydrocephalus (HCP)
- HCP 2
1. Obstructive
2. Non-obstructive
- Sign HCP
1. Tense bulging fontanelle
2. Sunset eye ( )
3. Increased HC
4. Superficial vein dilatation
5. Transillumination test +ve
6. fontanelle skull IICP Cushing reflex: Systolic HT, Reflex
bradycardia, Irregular respiration
- Ventriculostomy external drainage Acute HCP
- Shunt internal drainage Chronic HCP; 4
1. Ventriculo-peritoneal (VP)
2. Ventriculo-pleural
3. Ventriculo-atrial
4. Lumbo-peritoneal
- VP shunt
1. Infection Staph., Candida, E. coli
2. Malfunction Obstruction
3. Overdrainage
4. Disconnection ()
 TOP SI 117

Neuromuscular diseases
- Approach
1. Hx
- Onset
Acute/Subacute: AIDP, AFP
(AIDP = Acute inflammatory demyelinating polyradiculopathy, AFP = Acute flaccid paralysis)
Chronic: DMD/BMD
- Fluctuation of symptom: MG
- Associated symptom (): Peripheral n.
- Age
Neonate: SMA
Early childhood: DMD
Late childhood: BMD, MG
- Sex
Male: DMD/BMD
- FHx
XR: DMD/BMD
AR: SMA
AD: HMSN
2. Where is the lesion? Acute / Chronic
Lesion Acute Chronic
SC ATM
AHC Poliomyelitis, SMA
Non-poliomyelitis
PN GBS HMSN
NMJ MG
Muscle Acute myositis, DMD/BMD,
Dermatomyositis Congenital myopathy
(SC = Spinal cord, AHC = Anterior horn cell, PN = Peripheral n.)
Acute transverse myelitis (ATM)
- ATM = acute inflammation SC,
- PE: Weakness at lower limb ( upper limb ), Sensory level loss (60% T, 25%
C), Bowel/bladder dysfunction, Hyperreflexia / Areflexia (Spinal shock)
- Investigation
1. LP: cell , protein
2. MRI T2W1: Increased signal inflammation
 TOP SI 117

- Management: Supportive
Poliomyelitis
- Poliomyelitis Hallmark Asymmetry of flaccid paralysis
- Dx Stool for Polio virus
- Management: Supportive
Spinal muscular atrophy (SMA)
- SMA AR; mutation gene p arm chromosome 5 Progressive
degeneration of Anterior horn cell SC Motor nuclei Brain stem
- PE: Hypotonia, Hyporeflexia, Tongue fasciculation
Anterior horn cell signs: Tongue fasciculation, 2 Tremor-like,
Minimyoclonus
- SMA 3 major types
1. Type 1 (Werdnig-Hoffman disease) = Non-sitter Age onset < 6 mo.; severe ,
, PE: Areflexia
2. Type 2 = Sitter Age onset > 6 mo.; , PE: Hypotonia, Hyporeflexia, Tongue
fasciculation
3. Type 3 = Walker Age onset > 18 mo.; Hx ()
- SMA Respiratory complication (end up tube
death )
- Investigation: SMN gene ( 95%)
- Management
1. Supportive
2. Genetic counseling
Guillain-Barr syndrome (GBS)
- GBS AFP ; Peripheral n.; Ascending paralysis
( Descending paralysis: Botulism)
- 70-80% URI / GI symptom / Vaccination , ,
/ (Glove-stocking pattern)
- PE: Symmetrical weakness, Hyporeflexia / Areflexia
- Investigation
1. LP: Cyto-albumino dissociation ( cell CSF protein )
2. PNCV (Peripheral n. conduction velocity): Demyelination
- Complication : Respiratory failure, Autonomic instability, Pressure sore, Sepsis
- Management
1. Supportive
2. IVIG Respiratory failure /
 TOP SI 117

( IVIG refer D.10 Golden period )

Hereditary motor and sensory neuropathy (HMSN, Charcot-Marie-Tooth
disease, CMT)
- HMSN AD (/); Peripheral n.; Late childhood
- PE: Distal m. atrophy Steppage gait ( atrophy
), Pes cavus (High arch of foot)
- Investigation
1. PNCV / EMG
2. Gene analysis
- Management: Supportive; quality of life
Duchene / Becker muscular dystrophy (DMD/BMD)
- DMD/BMD XR ; Muscle Proximal m. weakness
- DMD Frameshift mutation ( Dystrophin ) severe; onset 3-5 yr.
BMD Shift-in-frame mutation ( Dystrophin ); onset Late childhood
- PE: Gowers sign ( , , , ), Waddling
gait ( ), Calf pseudohypertrophy ( )
Gowers sign, Calf pseudohypertrophy sign specific DMD sign
Proximal m. weakness ( SMA Gowers sign, Calf pseudohypertrophy )
- Investigation
1. CPK: high
2. Gene analysis: MPLA defect both deletion & duplication
- Management
1. Prednisolone
2. Supportive
Congenital malformation
Septo-optic dysplasia (SOD)
- SOD (De Morsier syndrome) = Septo: Septum pellucidum + Optic: Hypoplasia optic n.
wandering nystagmus, visual impairment, optic disc , global delayed development
- Management SOD Hormone replacement (e.g. Thyroxine )
 TOP SI 117

Genetics
Down syndrome (DS)
- Down syndrome clinical manifestation
1. Skin & hair Alopecia areata (AA), Straight pubic hair, Dry skin
2. HEENT
Head Brachycephaly, Microcephaly, Flat occiput, Flat face, Facial hypoplasia
Eye Upslant palpebral fissure, Epicanthal fold
Ear Small prominent low-set ear, Hearing loss (HL)
Nose Flat nasal bridge with small nose
Mouth Protrude tongue
3. Hand Simian crease, Broad hand with short metacarpals, Clinodactyly of 5th finger
4. Foot Wide gap between 1st & 2nd toes
5. CVS Endocardial cushion defect (ECD), VSD, ASD, TOF, PDA
6. GI Esophageal/Duodenal atresia, TE fistula
7. GU Hypoplastic pelvis with wide flat iliac wings, Small penis with decrease testicular volume
8. NS Hypotonia, Moderate MR, Short stature
- Down syndrome risk
1. Atlanto-axial instability
2. Serious otitis media, Hearing loss
3. Sinus / NL duct / Pulmonary infection
4. Autoimmune, Hypo/Hyperthyroidism
5. Leukemia
6. Cataract, Myopia
7. DM
8. OSA
9. Cardiac abnormality
- F/U
1. X-ray Lateral C-spine (Flex-Extend) at 5-18 mo., 10-12 yr., 18 yr., then q 10 yr.
2. TFT at Newborn, then q 2-3 yr.
3. Eye examination at 6-12 mo., then q 4 yr.
4. Cardiac evaluation (CXR, Echo, EKG) at < 6 mo.
Turner syndrome
- webbed neck Turner syndrome (XO)
webbed neck Noonan syndrome (AD)
Neurofibromatosis (NF)
 TOP SI 117

- NF 2 types NF1 & NF2

- NF1 (von Recklinghausens disease) criteria Dx 7 2/7
1. 6 Caf-au-lait spots > 5 mm before puberty, > 15 mm after puberty
2. 2 Neurofibroma 1 Plexiform neurofibroma
3. Axillary/Inguinal freckles
4. Optic glioma
5. Lisch nodules ( NF1)
6. Sphenoid dysplasia/Pseudoarthrosis
7. 1st degree relative NF1
- NF1 NF2
NF1 NF2
Common (1:2,500) Rare (1:25,000)
Manifestation Infancy-Childhood Manifestation Adult (20-30 yr.)
Neurofibroma, Caf-au-lait spots Hearing loss (HL), Tinnitus
Lisch nodules Cataract (PSC or Peripheral cortical
cataract), Epiretinal membrane (ERM)
Chromosome 17 Chromosome 22
Protein : Neurofibromin Protein : Merlin (Schwannomin)
AD
Inborn errors of metabolism
- Inborn errors of metabolism 3
1. Amino acid metabolism NKH, PKU
2. Organic acid metabolism MMA, MSUD, PA, IVA
3. Glycogen storage disease (GSD) ( Hepatosplenomegaly )
- seizure Inborn error of metabolism Acute encephalopathy
encephalopathy metabolic cause
- NKH (Non-ketotic hyperglycinemia) 24-48 hr. ,
- PKU (Phenylketonuria) > 2 wk.
- Inborn errors of metabolism urine 3
1. MSUD (Maple syrup urine disease) urine
2. PA (Proprionic acidemia)
3. IVA (Isovaleric acidemia) urine = Sweaty feet
3 Electrolyte HCO3- , wide AG
Other genetic diseases
Prader-Willi syndrome (PWS)
 TOP SI 117

- PWS microdeletion paternal 15q, maternal uniparental disomy

- = 3H: Hypotonia, Hypomental (delayed development), Hypogonadism, Obesity, Small
hands & feet
- Investigation: FISH for Chromosome 15q12
Dyskeratosis congenita (DKC)
- DKC AD, AR, XR; mutation Telomerase enzyme;
present skin lesion, pancytopenia
VACTERL association
- VACTERL association
Vertebral defect
Anorectal malformation (ARM)
Cardiac defect
TE fistula
Esophageal atresia
Renal anomalies
Limb defects
CHARGE syndrome
- CHARGE syndrome mutation gene chromosome 8;
Coloboma of eyes, CNS anomalies
Heart defect
Atresia of choanae (Choanal atresia)
Retardation of growth / development
Gonadal / urinary defect (Hypogonadism)
Ear anomalies / Deafness