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Post Graduate Interns Review
Veterans Memorial Medical Center

DEPARTMENT OF PEDIATRICS
North Avenue, Diliman, Quezon City
Herbert-Leonides C. Garcia, M.D.

Medical Officer III
NEONATOLOGY
herbert-leonides c. garcia, m.d.

Neonatal circulation
• Fetal – parallel circuit
3 important unique structures:
1) ductus venosus
2) foramen ovale
3) ductus arteriosus
• Newborn  adult – series circuit

Neonatology
1. Which of the following best describes the
neonatal circulation?
a. Parallel circuit
b. Series circuit
c. Dependent on PDA
d. None of the above

Neonatology
2. Foramen ovale is functionally closed at what
age of life?
a. 2 months
b. 3 months
c. 4 months
d. 5 months

Neonatology
3. 1 minute after birth, a baby delivered vaginally was
limp, with poor respiratory effort, acrocyanosis, no
response to nasal suctioning and CR 60s. At 5th minute
of life, baby had some flexion, with heart rate of 120
bpm, with pink body and bluish extremities, sneezes,
and good sustained cry. What is the Apgar score of the
baby?
a. 3, 8
b. 4,8
c. 5,9
d. 6,9

BIRTH INJURIES
A B
B 1. Cephalohematoma B 5. Limited to the surface of one
A 2. Caput succedaneum cranial bone
3. Cross the midline and B 6. No discoloration of overlying scalp
A
suture lines A 7. Edema, ecchymosis, and swelling
B 4. Subperiosteal apparent right after birth
hemorrhage B 8. May cause jaundice
Brachial Nerve Injuries
Paralysis Nerve Manifestation Others Treatment
Erb-Duchenne 5-6th CN Adduction, Presence of Conservative;
internal hand grasp is partial
rotation, good immobilization
pronation of prognostic sign and
the forearm; appropriate
extension is positioning to
preserved; prevent
biceps and contractures;
moro reflex brace or
absent splinting 1st 1-
Klumpke 7-8th CN, 1st Paralysis of 2wks
Thoracic hand, Monthly follow
ipsilateral up, surgical
ptosis and after 3 months
miosis (Horner if not
Sx) improving
Neonatology
4. The following are characteristic of caput succedaneum
except for one:
a. diffuse, sometimes ecchymotic, edematous swelling
of the soft tissues of the scalp involving the area
presenting during vertex delivery
b. may extend across the midline and across suture
lines
c. The edema disappears within the 1st few days of life
d. Associated w/ linear fracture

Neonatology
• Mechanisms of heat loss
– Heat energy transfer to the cooler surrounding air
• convection
– Heat transfer to the colder materials touching the infant
• conduction
– Heat transfer from the infant to other nearby cooler objects
• heat radiation
– Heat loss from skin and lungs
• evaporation

Neonatology
• Anterior fontanel – diamond shape, junction
of frontal and parietal, 2x2 cms, closes by 9-
18th months
• Posterior fontanel – triangular, junction of
parietal and occipital, closes by 6-8th weeks

Neonatology
5. Heat loss thru colder materials touching the
infant
a. Convection
b. Conduction
c. Heat radiation
d. Evaporation

Neonatology
6. Characteristic of pathologic jaundice
a. Onset of jaundice after 24 hours of age
b. A rise in serum bilirubin levels over 0.5
mg/dl/hour
c. Disappearance of jaundice at 4-5 days in a full-
term infant
d. Rise if serum bilirubin at less than 5 mg/dl/day

KERNICTERUS/ BILIRUBIN ENCEPHALOPATHY
• Results from deposition of unconjugated

Basal Brain
bilirubin in the ________
Ganglia and ________
Stem
• Kernectirus is rare in healthy infants if the

25
serum level is less than _______ mg/dl
• Clinical manifestation
– Phase 1 – poor sucking, stupor, hypotonia, seizure
– Phase 2- hypertonia, opisthotonus, fever
– Phase 3 - hypertonia

JAUNDICE IN THE FIRST 24 HOURS
KEY CLUE MOST LIKELY ETIOLOGY
First born child

ABO INCOMPATIBILITY
Second born Child

RH INCOMPATIBILITY
History of prolonged second stage

of labor SEPSIS
No prenatal Check Up
History of maternal infection during

pregnancy TORCH INFECTION

JAUNDICE AFTER THE FIRST 24 HOURS
ONSET OF JAUNDICE KEY CLUES MOST LIKELY
ETIOLOGY
2-3 days Baby otherwise normal PHYSIOLOC

JAUNDICE
3-4 days Mother has inadequate

breastmilk BREAST FEEDING
JAUNDICE
> 1 week Baby is purely breast fed

BREAST MILK
JAUNDICE

Neonatology
7. Which of the following are correctly paired?
a. G6PD deficiency - Mental retardation
b. Congenital Adrenal Hyperplasia - Death
c. Galactosemia - Anemia
d. Phenylketonuria - Leucine
e. Congenital Hypothyroidism - Cataract
f. Maple syrup urine disease - Kernicterus

NEONATAL INFECTIONS
CASE KEY CLUES DIAGNOSIS
A newborn presents with Baby is 3 days old

irritability, hypothermia, Early Onset Sepsis
poor feeding, and tremors
Baby is 2 weeks old
Late Onset Sepsis
Newborn not eating Delivered at home by
properly since the 4th day
after delivery and had 2
a comadrona.
NEONATAL
episodes of seizure and had
become increasingly stiff TETANUS

Vesicular lesions on the face
An IUGR and mouth HSV
baby born
Purpuric hemorrhagic lesions
to a mother all over the body RUBELLA
with history Maculopapular rash CONGENITAL
of infection Imaging: Periostitis of the
bone SYPHILLIS
during
Chorioretinitis
pregnancy Imaging: Periventricular CMV
calcifications
Chorioretinitis
Microcephaly
Hepatosplenomegaly
TOXOPLASMOSIS
Imaging: Intracerebral
calcifications
Cutaneous scars
Imaging: Cortical atrophy VARICELLA
Neonatology
8. An IUGR baby born to a mother with history
of infection during pregnancy with Chorioretinitis,
Microcephaly, Hepatosplenomegaly and on
imaging was noted to have Intracerebral
calcifications
a. Congenital Syphillis
b. Congenital Rubella
c. Toxoplasmosis
d. HSV

OBSERVATION OTHER PHYSICAL DIAGNOSIS
FINDINGS
Increased nuchal folds Edema of the feet and
Turner Syndrome
hands
Webbing of the neck
Hypotonic baby
Sandal toe deformity Down Syndrome
Slanted palpebral fissure
Distinguished facie
PHYSICAL DIAGNOSIS DIAGNOSIS
EYES Red Reflex
Normal
White Reflex
Retinoblastoma
Lens Opacity
Cataract
Aniridia
hemihypertrophy Wilm’s Tumor
NOSE Blue baby pinks up on
crying, catheter Choanal Atresia
doesn’t pass nose

PHYSICAL FINDINGS DIAGNOSIS
Open and closed comedones or
inflammatory pustules and papules on the
cheeks of the baby usually after a week Neonatal Acne
from delivery
Pink macular lesions on the nape, glabella,
upper eyelids, or nasolabial region Nevus Simplex
Hair that covers the skin of preterm infants.
Seen on term infants around the shoulders. Lanugo
Thick, white creamy material usually absent
in post term infants Vernix Caseosa
Mottling of the skin with venous
prominence. Cobbletstone, lacy Cutis Mormorata
appearance
Pale halves, transient
Harlequin color change

IMMUNIZATION/WELL CHILD

Immunization
• Type
– Active
– Passive
• T lymphocyte/B lymphocyte Dependent
• Parts of the vaccine
– Immunizing agent, conjugate, preservative, stabilizer,
antimicrobial agent, adjuvant
• Classes of vaccine
– Whole inactivated, parts, polysaccharide capsules, live
attenuated, toxoid
• Complications
- pain
- hypersensitivity
Vaccine Minimun Age # Of Doses Minimum Interval Route
Of 1st Dose Between Doses
BCG birth 1 n/a ID
DPT 6 wks 3 4 weeks IM
OPV/IPV 6 wks 3 4 weeks IM/Oral
HEPA B Birth 3 4 weeks IM
MEASLES 9 mos 1 n/a SQ
MMR 15 mos 1 n/a SQ

Vaccine Minimun Age # Of Doses Minimum Interval Route
Of 1st Dose Between Doses
PCV/ 6 weeks 3 4 weeks IM
PPV 2yo 5 years IM
Varicella 1 yo 2 3 months SQ
Hepa A 1 yo 2 6 months IM
Flu 6 months 2 4 weeks IM/SQ
Typhoid 2yo 2 years IM
Meningo 9 mos/2yo 1/2 IM
Rotavirus 1/5 6 weeks 2/3 4 weeks Oral

strains
Rabies Pre-ex 3 0,7,21/28 IM/ID

Post-ex 4 0,3,7,28 ID
herbert-leonides
5 c. garcia, m.d. 0,3,7,14,28 IM
Immunization
9. Which of the following vaccines are live
vaccines?
a. IPV, Hepatitis A
b. DPT
c. MMRV
d. Meningococcal and PCV

Immunization
10. Which of the following statements is true
regarding Hepatitis B Vaccination?
a. Needs booster dose if given on a 0,1,6 schedule
b. For mothers with (+)HBsAg, Hepatitis B vaccine
and Hepa B IG should be given to the newborn
within 24 hours
c. For babies delivered preterm, with a BW
<1500gms, the dose given at birth is not considered
as valid and should receive additional dose

Preventive
Deworming Drug Age Dose Conditions
Albendazole 1yo-2yo 200mg Effect of food
>2yo 400mg When to
repeat
Mebendazol >1yo 500mg
e
Iron Condition Dose

Supplementation
Preventive 1-2mkdose
Therapeutic 3-6mkdose

Preventive
11. A 2yo child came in for routine check up.
On examination, you noticed the patient to
have palmar pallor and tachycardic. If you are
going to prescribe iron supplement for this
patient, what will be the dose?
a.1-3mkd
b. 2-4mkd
c. 3-6mkd
d. 4-8mkd

Retinopathy Of Prematurity
• Risk factors
– Age of gestation, <32 weeks
– Low birth weight, 1500gms
– Infants weighing 1500-2000 gms with stormy
course

Feeding
• Milk feeding
• Complementary
• Supplementary

Whey:Casein
Breastfeeding/Milk
Breast milk
60:40
Cow’s milk
20:80
Water (ml/dl) 87.1 87.2
Energy (kcal/dl) 75 66
Protein Alpha lactalbumin Beta lactalbumin
Curd Softer, smaller, sweeter Lesser
Digestion Complete, faster, efficient Lesser
Fat Long chain unsaturated fatty Saturated fatty acids
acids; polyunsaturared fatty acids (9%)
(1.3%)
Lactose 7% 4.8%
Mineral/Electrolyte Lower Higher
Iron Lower Higher
Vitamins Higher Vit A, B3, C, D, E Higher B1, B2, B6,

herbert-leonides c. garcia, m.d. Folate, K
Milk Feeding
12. True of breastmilk
a. Contains beta lactalbumin
b. Less calorie dense than cow’s milk
c. 20:80 whey to casein ratio
d. Promotes faster bowel movement

Contraindications to Breastfeeding
• HIV
• TB
• Varicella
• HSV
• CMV
• Hepatitis B
• Chemotherapy
• Alcohol intake

Milk Feeding
13. Absolute contraindication to breastfeeding
a. Chemotherapy
b. Varicella infection
c. Herpes infection
d. Hepatitis B infection

Milk Feeding
14. True of complementary feeding

a. Should be started as early as 3 months of life
b. Energy density should exceed that of breast milk
c. Introduce 2 foods at a time
d. Fluids other than milk and water can be given

GROWTH AND DEVELOPMENT

Neonatal period
• Average wt – 3.4kgs ( 7 ½ lbs), boys > girls
• Length - 50 cms (20 in)
• HC – 35 cms (14 in)
• Nearsighted, fixed focal length 8-12 inches
• Turns preferentially to a female voice
• 10% weight loss in the 1st week, regained/exceeded
by 2 week of age
• 30gm (1 oz)/day

The first year
• By 3-4 months, 20g/day
• 4th month - wt doubled, disappearance of tonic
neck reflex, begin to manipulate objects with both
hands
• Crying – peaks by 6 weeks up to 3hr/day then
decreases to <1hr by 3 mos
• Object permanence
• Stranger anxiety
• Introduction of transitional object
• 1st bday – wt tripled, length ↑50%, HC↑10cms

Growth and Development
• 1st Yr – 2nd Yr
– Short legs, long torsos, exaggerated lumbar lordosis,
protruding abdomens
– Increase in HC 2cm
– Wide based gait, genu varus (bowleg)
– Receptive language preceded by expressive,
“polysyllabic jargoning”
– Separation anxiety at bedtime
– “Transitional object”

Preschool (2-5yo)
• By 24 months, ½ of ultimate adult height, +7-8cms/yr
• 2 ½ yo – BW 4x, +2kgs/yr
• 90% of adult HC, +5 cms 3-18yo
• 4yo – 40lbs, 40inches
• Somatic and brain growth slows,
• Emergence of picky eating habits
• Genu valgum
• Mild pes planus
• Torso slims as the legs lengthen
• Physical energy peaks

Preschool (2-5yo)
• Need for sleep declines, dropping the nap
• VA: 20/30 at 3yo; 20/20 at 4yo
• 3yo - 20 primary teeth erupted
- mature gait
- handedness
• Bowel and bladder control
• Rapid language development
• Stuttering
• Discipline – process that allows child to internalize control
on behavior

15. Typical of a pre-schooler
a. Genu varus
b. Transitional object
c. Exaggerated lumbar lordosis
d. Emergence of picky eating habits

Developmental Milestones
16. Which of the following can a 4 year old child
do?
a. Rides tricycle
b. Walks up and down stairs, one step at a time
c. Hops on one foot
d. Pretends in play

Developmental Milestones
• Which of the following is properly paired
a. Draws circle – 4yo
b. Draws square – 3yo
c. Dresses and undresses – 5yo
d. Makes tower of 3 cubes – 18 months

Adolescence
Period Early Middle Late
SMR 1-2 3-5 5
Somatic Awkward appearance Acne and body odor Physically mature
Menarche/
spermarche
Self concept Preoccupied with Attractiveness Stable body image

changing body Stereotypical Firmer identity
Fantasy and present adolescent
oriented
Peers Peer affiliation to Intense peer group Intimacy/

counter instability involvement commitment takes
precedence
Sexual Genital changes/size Initiation of Intimacy/stable
relationships/sex relationship/future
and commitment
Adolescence
17? Which stage of adolescence is concerned
with attractiveness and intense peer group
pressure?
a. Early adolescence
b. Middle adolescence
c. Late adolescence
d. Very late adolescence

Weight
• <6 months
– BW + (age in months x 600gm)
• >6 months
– BW + (age in months x 500gm)
• 1-6yo
– Age in years x 2 + 8
• 7yo and above
– Age in years x 7 – 5
2

Height
• < 1 yo, 25cms
– 1st quarter – 9 cms
– 2nd quarter – 8 cms
– 3rd quarter – 5 cms
– 4th quarter – 3 cms
• > 1 year old
– Age in years x 5 + 80 cms

RESPIRATORY

PATIENTS PRESENTING WITH PNEUMONIA
CLINICAL KEY CLUES MOST LIKELY ORGANISM
VIGNETTE
Poorly nourished
Patient with Unvaccinated
fever, With onset of rashes all over the MEASLES
body
cough, and
Patient has CF
tachycardia Patient has CGD
PSEUDOMONAS
Patient is a burn patient
Patient is neutropenic
Patient is a teen/young adult
MYCOPLASMA
Lives in a dormitory
Inital cough is non productive
Patient has his own aviarium in his
CHLAMYDIA PSITTACI
home
Hx of eye discharge during the first 5-
14 days of neonatal period CHLAMYDIA TRACHOMATIS

PATIENTS PRESENTING WITH PNEUMONIA
CLINICAL VIGNETTE CXR FINDINGS DIAGNOSIS
Child with Lobar consolidation

S. pneumonia
Cough Hyperinflation with bilateral interstitial
Cold infiltrates and peribronchial cuffing
VIRAL RSV
Fever Prominent areas of cavitations and

S. aureus
multiple pneumatoceles
Wheezing Right sided hilar adenophathy
Stridor TB

• What is the most consistent clinical manifestation of pneumonia?
TACHYPNEA
• What is the definitive test to confirm diagnosis?
CULTURE OF BLOOD, PLEURAL FLUID
• What is the recommended drug for children suspected of bacterial
pneumonia who do not require hospitalization?
AMOXICILLIN
• What is the empirical treatment for hospitalized children with

suspected bacterial pneumonia?
PARENTERAL CEFUROXIME
• If features suggest Staph. Aureus infection, what should be included

in the drug regimen? VANCOMYCIN OR CLINDAMYCIN
• For suspected M. Pneumoniae patients, what is the antibiotic of

choice?
MACROLIDE
TYPE OF COUGH DIAGNOSIS
Staccato CHLAMYDIA PNEUMONIA
Brassy S. AUREUS (BACTERIAL TRACHEAITIS)
Barking “Seal” PARAINFLUENZA (CROUP)
Whooping PERTUSIS
Post-tussive vomiting
Most severe in the morning CYSTIF FIBROSIS
With vigorous exercise ASTHMA
Disappears with sleep HABITUAL COUGH
Tight sounding with ASTHMA

wheezing herbert-leonides c. garcia, m.d.
Respiratory
18. What is the most reliable clinical indicator of
pneumonia?
a. Tachypnea
b. Hypoxia
c. Fever
d. Crackles

CASE: preterm with severe respiratory distress
• Diagnosis:
Hyaline Membrane
Disease
• Treatment:
Exogenous Surfactant
CPAP
• Prevention:
Steroids 48-72 hours
fine reticular prior to delivery
granularity and air
bronchogram
CASE: Term infant via vaginal delivery with
respiratory distress
• Diagnosis:
Neonatal Pneumonia
• Most likely etiology:
GBS
• Management:
Ampicillin +
Aminoglycosides
Perihilar streaking
Respiratory
19. Most common cause of pneumonia in a term
infant delivered vaginally
a. Group A Streptococcus
b. Group B Streptococcus
c. E. coli
d. Hib

CASE: A term infant via CS with respiratory
distress. Normal physical findings.
PROMINENT
PULMONARY
MARKINGS
• Diagnosis:
TTNB
• When do you expect

the patient to
recover?
3-5 days
Fluid lines in fissures.
Overaerated
• How do you differentiate it
with other pulmonary
disease?
Sudden recovery of the baby on
about the 3rd day
CASE: post-term infant with respiratory distress
• Diagnosis:
MECONIUM
ASPIRATION SYNDROME
• Treatment
SUPPORTIVE
Coarse,streaking
of both lungs
RESPIRATORY CONDITIONS IN THE NEONATE
CXR PATTERN CONDITION

Finely granular lungs
Ground glass appearance HMD
Prominent pulmonary vascular markings
Fluid lines in fissure TTPN
“bubbly lungs” (cystic lucencies)
BPD
Coarse streaking granular patter of both
lungs fields MECONIUM ASPIRATION
Perihilar Streaking NEONATAL PNEUMONIA

• What is the most common
congenital laryngeal anomaly LARYNGOMALACIA
and the most frequent cause

of stridor in infants and
children?
congenital anomaly of the CHOANAL ATRESIA
nose?
cause of nasal polyps in CYSTIC FIBROSIS
children less than 12?

• What are the two
sinuses present at MAXILLARY AND ETHMOIDAL
birth?
• What is the most KIESSELBACH’S PLEXUS
common bleeding site
in epistaxis?
• What is the single BLOOD GAS ANALYSIS
most useful test of
pulmonary function?
• What is the most
common cause of SIDS
post neonatal infant
mortality?

PULMONARY TUBERCULOSIS
• Transmission:
airborne
• Earliest symptoms
– non productive cough, dyspnea, CLAD
• The best culture specimen for children?
EARLY MORNING GASTRIC ASPIRATE
• Tuberculin sensitivity will develop how many

weeks after inhalation of bacilli?
3 WEEKS – 3 months

• Ghon’s focus/ lesion
– Parenchymal focus
• Ghon’s complex
– Parenchymal focus plus the regional lymph node
• Appearance of calcification implies that the
lesion has been present for at least?
6-12 MONTHS
• The HALL MARK of primary tuberculosis in the lung is the RELATIVELY LARGE
SIZE OF REGIONAL LYMPHADENITIS compared to the relatively small size of
the initial lung focus

• The most clinically significant
form of disseminated
Tuberculosis
MILIARY TB
• Most common form of

Extrapulmonary TB
SCROFULA/ TB OF THE LN
• Most serious complication of

TB TUBERCULOUS MENINGITIS
– Site of greatest involvement BRAINSTEM
– The Cranial nerves most CN 3, 6, 7
frequently affected

• Pott’s disease
– TB of the spine
• The most common radiographic presentation

of Reactivation tuberculosis
– Extensive infiltrates or thick walled cavities in the
upper lobes

TB Medications
DRUG MOA/Elimination DOSE AR
INH(H) Bactericidal 10-15 Peripheral
Hepatic neuropathy;
hepatotoxicity
RIF (R) Bactericidal 10-120 Gastrointestinal
Hepatic intolerance; fever,
thrombocytopenia,
flu-like symptoms
PZA (Z) Bactericidal 20-40 Hypersensitivity;
Hepatic Arthralgia , Inc.
transaminases
Strep (S) Bactericidal 20-40 Vestibular/Auditory;
Renal hemolytic anemia
Etham (E) Bacteriostatic 15-25 Retrobulbar neuritis
Renal (reduced VA, green-
red color blindness

TB Medications
20. Which of the following TB medications
causes tinnitus?
a. INH
b. Rif
c. PZA
d. Etham
e. Strep

TB in children
• Which of the following is not a key risk factor
for the development of TB in children?
– A. Household contact with a newly diagnosed
smear (-) case
– B. Age <5yo
– C. HIV infection
– D. Immunocompromised state

PATIENT PRESENTING WITH COMMON COLDS
CLINICAL VIGNETTE KEY CLUES DIAGNOSIS
Prominent itching and sneezing
Patient Nasal eosinophilia Allergic rhinitis
presents Unilateral foul smelling discharge
Bloody nasal secretion Foreign body
with sore,
scratchy Headache, facial pain,
periorbital edema
Sinusitis
throat, Rhinorrhea for more than 2
weeks
nasal Persistent rhinorrhea with onset
Congenital syphillis
obstruction in the first 3 months of life
(snuffles)
and Hx of prolonged use of topical or
Rhinitis medicamentosa
oral decongestant
rhinorrhea
Paroxysms of cough leaving the
baby breathless and Whooping cough
subconjunctival hemorrhages
• What is the most common pathogen associated with
common cold? Rhinovirus > Corona Virus
• Children have an average of how many episodes of
colds per year? 6-8 times per year
• Among the viruses that cause colds, which is the only
one efficiently transferred through small particle
aerosols? Influenza virus
Scratchy sore
• What is the first symptom of common cold? throat
• Does the presence of PMN leukocytes in the nasal

secretions in uncomplicated colds indicate bacterial
superinfection? NO!

Respiratory
• What is the most common complication of a
cold? OTITIS MEDIA
• What is the drug that reduces the frequency

of influenza associated complications? When
should it be started?
OSELTAMIVIR WITHIN 48 HOURS OF
SYMPTOMS

FOREIGN BODY: TRACHEA OR
ESOPHAGUS?
ESOPHAGUS TRACHEA
Foreign Body
• Children <3yo
• Most common – peanuts
• Most serious complication – complete
obstruction of the airway
• Stages – 1.initial event
2. asymptomatic interval
3. complication
• Most common site – right bronchus

Foreign body
21. True of foreign body aspiration in children
a. Common in children >3yo
b. Plastic materials are the most common
c. Complication includes hemoptysis
d. Most common site is the trachea

KEY CLUES PHYSICAL EXAM DIAGNOSIS
Patient Onset is sudden Patient is drooling and is in

presents with with high fever tripod/sniffing position
stridor and No history of Patient is toxic looking
cough and colds ACUTE EPIGLOTITIS
signs and among family
Patient has severe air hunger
symptoms of members dysphagia
upper
respiratory Hx of cough and Patient is toxic looking, high
obstruction colds among fever BACTERIAL TRACHEITIS
family members But no drooling
No dysphagia
Barking cough CROUP
Inspiratory stridor
Mild respiratory distress but
Patient is 4 otherwise well
months old.
No history of
cough and colds.
Stridor and
LARYNGOMALACIA
dyspnea are
exacerbated by
crying or
feeding.
Gray-white membrane covering
the tonsils and soft palate DIPHTERIA
PATIENTS PRESENTING WITH UPPER AIRWAY OBSTRUCTION
CLINICAL CXR FINDINGS Dx and TREATMENT

VIGNETTE
Patient presents Patchy infiltrates and ragged
with signs and tracheal air column ANTISTAPHYLOCCOCAL
symptoms of ANTIBIOTICS
upper
“thumb’s sign” INTUBATION
respiratory
obstruction
Sub glottic narrowing NEBULIZED RACEMIC EPINEPHRINE
Air trapping on the right lung

with mediastinal shift
towards the opposite side RIGID BRONCHOSCOPY
“Steeple sign”
NEBULIZED RACEMIC EPINEPHRINE
PATIENTS PRESENTING WITH WHEEZING
CASE VIGNETTE KEY CLUES DIAGNOSIS
Patient presents to History of viral infection among

you with wheezing the family members. BRONCHIOLITIS
Patient is 2 years old.
History of atopy in the family .

Recurrent wheezing especially ASTHMA
after mild viral infection or after
exercise
Wheezes are heard loudest over
the trachea. Persistent CHONDROMALACIA
wheezing never seems to go
away.
Absent breath sounds on right FOREIGN BODY
lung. Patient is 3 years old. OBSTRUCTION

HEMATOLOGY

IRON DEFICIENCY ANEMIA
• The most common hematologic disease of infancy and
childhood
• Most common in ____months
9-24 of age
• Most common cause is______________
Decrease dietary intake
• _________
Pallor is the most important sign
• Hgb <7-8g/dl – pallor of palms, palmar crease, nail
beds, conjunctivae
• Hgb <5g/dl – irritability, anorexia, lethargy, systolic flow
murmur
• Pica – ingestion of non nutritive substances
– plumbism
• Pagophagia – desire to ingest ice

RESPONSES TO IRON THERAPY
TIMING BODY RESPONSE

12-24 HOURS Subjective improvements in patients
24-48 hours Initial bone marrow response
48-72 Reticulocytosis
4-30 days Increasing hemoglobin level
1-3 months Repletion of iron stores

Anemia
22. True of iron deficiency anemia
a. Serum ferritin is the most useful
laboratory measure of iron status
b. Normocytic, hypochromic anemia
c. RDW is normal
d. Total iron binding capacity is decreased

Anemia
Disease PAI IDA ACD MA
Age infancy 9-24 months older 4-7months (FA)
Older (B12)
Pathology Down regulation Iron deficiency Erythrophagocytosis FA or B12
of EPO deficiency
Type Normocytic Microcytic Normocytic/ macrocytic
Microcytic
EPO Decreased Normal Increased/ Normal
Decreased
Iron Normal/low low normal normal
Test none Serum ferritin Depends on the Serum LDH
underlying Urine
Disease Methylmalonic
acid
Therapy None Iron Cure underlying FA 1mg
Ensure adequate cause B12
milk/nutrition
Thalassemia/Sickle cell
Type variant Pathology Manifestation Complications Treatment
Alpha Trait Absence Anemia

SEA Major /reduction of Hydrops
alpha chain fetalis Chronic
Severe
Beta Trait Absence Thalassemic transfusion
anemia
European Intermedia /reduction of facies, Fx, Chelation
Iron Toxicity
Thalassemia beta chain HSmegaly Therapy
major/
Cooley’s (QUANTITY)
Sickle cell Trait (HAS) Single base Bacterial Dactylitis Hydoxyurea
Disease (HS) pair change, sepsis Acute splenic Exchange
C (Lysine) 6th codon B Functional sequestration transfusion
globin asplenia Priapism
(adenineT
hymine;
glutamine 
valine)
(QUALITY)
Hematology
23. True of Thalassemia
a. Inherited as autosomal dominant
b. Carrier parents will have a 25% chance
of having an affected child
c. Pathology is secondary to quality of
globin chains produced
d. Causes autosplenia

G6PD deficiency
• G6PO4  6Phosphogluconic acid
• NADPH – reduced glutathione, prevents oxidative
stress -/- precipitation of HgB (Heinz bodies)
• X linked
• G6PD A – American of African descent
• G6PD B – Mediterranean, African, Asian
• G6PD Canton - Chinese
• Favism – fava beans acute severe hemolytic Sx
– G6PD B variant

Hematology
24. Which of the following best describes G6PD
deficiency
a. A variant is commonly seen in Mediterranean
patients
b. B variant is more severe
c. Autosomal recessive inheritance
d. Most patients are symptomatic

Bleeding DSO
Disease Variant Pathology Manifestation Others
Hemophilia A (X) VIII Spontaneous Hallmark

B (X)
C
Antihemophilic bleeding Hemarthrosis
(Autosomal) IX Xmas (ankles)
XI Plasma Inc PTT
Thromboplastin Severe <1%
Antecedent Mod 1-5%
Mild >5%
Parahemophilia AR V Mucocutaneous
hemorrhage
Hematomas
Severe
menorrhagia
vWD 1 (quantity) Absence of vWF Mucocutaneous Type 1 MC
2 (quality) hemorrhage
3 (absent)
(α granules, Weibel- Most common
Palade bodies) Menorrhagia hereditary
Autosomal
bleeding DSO
Hematology
25. True of haemophilia
a.Factors VIII and IX are the most common severe
inherited bleeding DSO
b.Hemophilia C is due to deficiency of Christmas
factor
c. Hemarthrosis appear most commonly in the
hands
d. Most bleeding are trauma induced

IDIOPATHIC THROMBOCYTOPENIC
• DIAGNOSIS: PURPURA
• TREATMENT: Education and Counselling
IVIG
Prednisone
Splenectomy (>4yo, Sx>1yr; Life
threatening hemorrhage)
GASTROINTESTINAL

CASE: A preterm baby won’t stop crying. Developed ABDOMINAL
DISTENTION with abdominal erythema. Baby cries more when touched.
• Xray shows thickened bowel

walls and air in the bowel wall
Pneumatosis Intestinalis
called _________________
• Intervention?
Supportive
• Xray 2 days later shows

pneumoperitoneum
• Intervention?
Call the Surgeon.
Gastrointestinal
• Esophageal atresia (EA) is the most common
congenital anomaly of the esophagus
• Of these, >90% have an associated
tracheoesophageal fistula (TEF).
• In the most common form of EA, the upper
esophagus ends in a blind pouch and the TEF
is connected to the distal esophagus

Tracheoesophageal Fistula

CASE #2: A term infant born with extrusion of abdominal viscera.
• What is your immediate
intervention?
SILO WRAP
• Which one is associated

with other congenital
anomalies?
OMPHALOCOELE
• Gastroschisis is more
common on left side or
right side of umbilicus?
RIGHT SIDE

CASE: A preterm baby won’t stop crying. Developed ABDOMINAL
DISTENTION with abdominal erythema. Baby cries more when touched.
• Diagnosis?
Neonatal Necrotizing
Enterocolitis (NEC)
• Claim to fame:
Most common life threatening

Emergency of the GIT in the neonatal
period

CASE: A term infant with severe respiratory
disease. Scaphoid abdomen on PE
• Diagnosis:
Diaphragmatic Hernia
• Most common type:

Bochdalek Hernia
• Where is the lesion?
Posterolateral Foramen

• What is the most common congenital
abnormality in the GIT?
MECKEL’S DIVERTICULUM
• what is the most common cause of intestinal
obstruction in neonate?
HIRSCHSPRUNG DISEASE
• What is the most common cause of intestinal
obstruction in children 3 months- 6 years?
INTUSSUSCEPTION

Gastrointestinal
27. Most common cause of intestinal
obstruction in the neonate?
a. Intussusception
b. Meckel’s Diverticulum
c. Hirschsprung Disease
d. Functional Constipation

• Hall mark of gastric obstruction?
NON BILLOUS VOMITING
• The most common cause of non billous
vomiting is?
HYPERTROPHIC PYLORIC STENOSIS
• Triad of sudden onset of severe epigastric
pain, intractable retching with emesis, and
inability to pas a tube into the stomach?
GASTRIC VOLVULUS
• Hall mark of duodenal obstruction?
BILLOUS VOMITING

Patient presents with double bubble” sign
billous vomiting on cry DUODENAL ATRESIA
No abdominal
distention
Patient present with non “double tract sign”

billous vomiting Palpable olive
Peristaltic wave PYLORIS STENOSIS
Baby has not passed On rectal examination,

meconium for 3 days rectal vault is empty
HIRSCHPRUNG’S DISEASE
Child present with sudden Passed out currant

onset of severe abdominal jelly stool INTUSSUSEPTION
pain Abdomen is tender to
palpation
2 year old male child Passed out currant

presents with painless jelly stool MECKEK’S DIVERTICULUM
rectal bleeding for 8 days herbert-leonides c. garcia, m.d.
Gastrointestinal
• 99% of full-term infants will pass meconium
within? 48 HOURS
• COIL SPRING appearance in barium?
INTUSSUSCEPTION
• Presence of transition zone between normal

dilated proximal colon and smaller caliber
obstructed distal colon?
HIRSCHSPRUNG DISEASE

PATIENTS PRESENTING WITH NON INFLAMMATORY DIARRHEA
Watery Day care center
Infants and toddlers ROTAVIRUS
diarrhea
vomiting Profuse diarrhea and
vomiting
CHOLERA
Flecks of mucous on
voluminous diarrhea
Profuse diarrhea after
VIBRIO
eating raw oysters or
PARAHAEMOLYTICUS
undercooked shellfish
Greasy stool after camping
GIARDIA LAMBLIA
Watery diarrhea with

vomiting after history of ETEC
travel
Gastrointestinal
28. Which of the following organisms is
associated with eating improperly cooked
hamburger?
a.Shigella
b.Salmonella
c.Clostridium
d.EHEC

PATIENTS PRESENTING WITH INFLAMMATORY
DIARRHEA/DYSENTERY
Bloody Trophozoites with ingested RBC’s
ENTAMOEBA HISTOLYTICA
diarrhea
Pus and Abdominal cramps, systemic
toxicity after antibiotic use CLOSTRIDIUM DIFFICILE
WBC in the
stools Abdominal cramps, tenesmus,
abundant pus and WBC in the SHIGELLA
stool
high fever, headache, drowsiness,

confusion, meningismus, seizures,
abdominal distention SALMONELLA
-history of eating eggs, poultry,
un pasteurized milk
Diarrhea with blood after eating
hamburger EHE C

PATIENTS PRESENTING WITH WATERY DIARRHEA FROM FOOD
INTOXICATION
Abdominal Ham, potato, salad,
cramps cream pastries
Diarrhea S. AUREUS
Sweating
No fever
Reheated fried rice
B. CEREUS
Home-canned food
Muscle weakness
Diplopia C. BOTULINUM
Blurring of vision

NUTRITIONAL DERMATOSES
NUTRIOTIONAL DERMATOSES
CHARACTERISTIC LESION OTHERS NUTRITIONAL DEFIECIENCY

Vesiculobullous, eczematous, Chronic diarrhea
dry scaly or psoriasiform lesions Stomatitis
symmetric perioral ,acral and Glossitis ZINC DEFICIENCY
perianl areaas Irritability
superinfection
Generalized scaly dermatitis Alopecia
Thrombocytopenia ESSENTIAL FATTY ACID
Failure to thrive
Edema, erythema and burning of Diarrhea

sun exposed skin on the face dementia
neck hands on butterfly NIACINE DEFICIENCY
distribution dermatitis around
the neck
Alopecia with neurological

symptoms BIOTIN DEFICIENCY
Follicular Xerosis
Night blindness VITAMIN A DEFICIENCY
hyperkertosis
Perifollicular erythema and
hemorrhage VITAMIN C DEFICIENCY
Bleeding swollen gums
CHARACTERISTIC DEFICIENCY INTOXICATION
•Dry silver gray plaques on the bulbar

conjunctiva VITAMIN A
•Photophobia
•Drying of the conjunctivae, cornea, and
lichenificaion of epithelium
NV, bulging of fontanel, pappiledema, CN
palsies and other symptoms suggestive of brain VITAMIN A
tumor
•Cyanosis and dyspnea with tachycardia and
enlargement of liver VITAMIN B1
•Increased QT interval and other ECG changes
•Dilated heart and fatty degeneration of of the
myocardium
Megaloblastic anemia without CNS signs and
VITAMIN B9
symptoms
Megaloblastic anemia with CNS signs and VITAMIN B12

symptoms herbert-leonides c. garcia, m.d.
CHARACTERISTIC DEFICIENCY
•Thinning of the outer table of the skull

•Palpable enlargement of the costochondral junctions
and thickening of the wrists and ankles VITAMIN D
•Sternum with adjacent cartilage appearing forward or
with horizontal depression
•Symmetric areas of erythema on exposed surfaces

resembling sunburn NIACIN
•Depression, delirium, insomnia, and delirium
•Irritability and generalized seizures VIT B6

Associated with hemolytic anemia
cerebellar ataxia, peripheral neurophaty, and posterior VITAMIN E
column deterioration
Bleeding from umbilical stump VITAMIN K
Brawny dermatitis, orofacial lesions, alopecia,
hyperesthethia. BIOTIN
Vitamins
29. Which vitamin deficiency is associated with
irritability and generalized seizures?
a.Vitamin A
b.Vitamin B3
c.Vitamin B6
d.Vitamin D

CARDIOLOGY
MURMURS
INNOCENT PATHOLOGIC
• Soft • Diastolic
• Systolic
• Short
• Pansystolic
• Sounds “musical” “vibratory” • Late systolic
“twangy” • Continuous
• Symptomless
• Special tests normal (X-ray, EKG) • Thrill present on
• Standing/ Sitting (vary with examination
position) • Additional cardiac
• Second grade only (up to Grade II abnormalities (e.g., clicks,
only)
• Sternal border (left or midsternal) abnormal splitting,
asymmetric pulses)

ACYANOTIC HEART
DISEASE CYANOTIC HEART
(LEFT TO RIGHT SHUNT) DISEASE
DECREASE PULMONARY BF:

PULMONARY ATRESIA
VSD PULMONARY STENOSIS
TOF
ASD TRICUSPID ATRESIA
EIBSTEIN ANOMALY
PDA
COA INCREASE PULMONARY BF:
ECD TOGA
TAPVR
TRUNCUS ARTERIORUS
Cardiology
30. Which of the following CHD will present as
acyanotic?
a.Transposition of the great arteries
b.Coarctation of the aorta
c.Pulmonary Stenosis
d.Tetralogy of Fallot

CASE PHYSICAL EXAMINATION DIAGNOSIS
A child is Late systolic murmur with MVP
an opening click
presented to
Disparity in pulsation and
you with blood pressure in the
complaints of arms and legs COA
exercise Weak popliteal, posterior
tibial, and dorsalis pedis
intolerance, easy pulses
fatigability. S2 widely split and fixed in
ASD
all phases of respiration
Loud, harsh, blowing
holosystolic murmur VSD
Wide pulse pressure

Bounding peripheral PDA
arterial pulses
Continuous murmur

CHILD PRESENTING WITH CYANOSIS
• Cyanosis manifesting within few hours at birth

or within few days of life.
TRANSPOSITION OF GREAT ARTERIES
• Cyanosis manifesting after the first year of life,
usually an infant or a toddler.
TETRALOGY OF FALLOT

SURGICAL OPERATIONS
SURGICAL PROCEDURE INDICATION
Blalock- Taussig Shunt with TOF
GoreTex conduit
Aortopulmonary window shunt
Waterson Cooley
Pott shunt
Rashkind atrial septostomy TRANSPOSITION OF THE GREAT ARTERIES
Jantene arterial switch
Senning and Mustard
Fontan procedure Tricuspid atresia
Norwood procedure HYPOPLASTIC LEFT HEART SYNDROME

Glenn anastomosis

CARDIAC MOST MOST
COMMON
COMMON
Cardiac ANOMALY BICUSPID AORTIC VALVE
Congenital Heart Disease VSD
Congenital Heard Disease diagnosed in adults ASD
Cyanotic heart disease TOF
CHD in Down Syndrome AV CANAL DEFECT or ECD
Type of ASD Ostium secundum

Type of VSD Membranous VSD
Type of TAPVR Supracardiac
Type of Coarctation of Aorta Adult (juxtaductal) type
Stenosis/ Calcification of Mitral Valve Rheumatic heart disease
Stenosis/calcification of Aortic valve Bicuspid aortic valve
Tumor of the heart ` Rhabdomyoma
Congestive Heart Failure in first 24 hours of life Intrauterine arrhythmia
Cardiology
31. 2yo child with single transverse palmar
crease, large tongue, upslanting of the palpebral
fissure and cardiac murmur. Most likely, which of
the following CHD does the patient have?
a.ECD
b.VSD
c.PDA
d.TOF

CXR FINDINGS DIAGNOSIS
Boot shape/ coeur en sabot TOF
Egg on String TGA
Snowmann TAPVR
Figure of 8 TAPVR
Rib Notching COA
Inverted E COA
3 sign COA

CONDTION DIAGNOSIS
PDA
RUBELLA
TOGA, VSD
DM
COMPLETE HEART BLOCK
LUPUS
PPHN
ASPIRIN
PULMONIC STENOSIS VSD
ALCOHOL
EBSTEIN ANOMALY
LITHIUM

INFECTIVE ENDOCARDITIS
CASE KEY CLUE ORGANISM
Chills, fever, arthralgia, Developing a new heart
myalgia, actutely ill looking murmur S. AUREUS
CASE KEY CLUE ORGANISM
A child with known CHD Patient has poor oral

presents with fever, fatigue, hygiene S. VIRIDANS
weight loss , painful skin
lesions on the fingers
Patient just underwent root

S. VIRIDANS
canal
Recent repair of VSD FUNGAL
Child is an IV drug user

PSEUDOMONAS
CLASSIC SKIN LESIONS
OSLER NODES JANEWAY

SPLINTER
HEMORRHAGES

RHEUMATIC HEART DISEASE
• What is the most frequent earliest
manifestation of RHD? ARHTRITIS
• What is the most common major

manifestation of RHD MIGRATORY
POLYARTHRITIS
• What is the rarest of all the major
manifestations? SUBCUTANEOUS NODULES
• What is the drug of choice for Sydenhan

Chorea PHENOBARBITAL

RHEUMATIC HEART DISEASE
• What is the most serious
PANCARDITIS
manifestation of RDH
• The universal finding in

Rheumatic carditis CARDIAC MURMUR
• May occur as the only CHOREA

manifestion of RHD

Cardiology
32. Which of the following may occur as the only
manifestation of RHD?
a.Carditis
b.Arthritis
c.Chorea
d.Erythema marginatum

INFECTIOUS

Infectious
• A 1 year old child came into your clinic due to
poor oral intake. CR: 120 RR 28 Temp 38C. Upon
physical examination, patient had hyperemic
pharyngeal wall with vesicles and maculopapular
lesions on the hands and feet. Which of the
following is the most likely diagnosis?
a. Roseola Infantum
b. Herpangina
c. Hand, foot and mouth disease
d. German Measles

TYPE OF KEY CLUES CAUSATIVE AGENT DRUG OF CHOICE
INFECTION
Conjunctivitis Red itchy eyes
with purulent CEFTRIAXONE
discharge onset 2- N. Gonorrhea SINGLE DOSE IM
5 days
Red itchy eyes
with purulent ERYTHROMYCIN
C. Trachomatis
discharge onset 5- QID 14 DAYS
10 days
• What is the most frequent identifiable
infectious cause of neonatal conjunctivits?
C. TRACHOMATIS

CONJUNCTIVITIS IN CHILDREN
EYE INFECTION KEY CLUES DIANOSIS
CONJUNCTIVITIS •Red itchy eye (s)

•Thin exudate
•Pain and photopobia ADENOVIRUS
•+/- Cough and colds
•Red eyes
•Presence of pus S. AUREUS
•Red eyes
•Pus CHLAMYDIA
•Inclusion bodies in TRACHOMATIS
scrapings
•Inturned eyes lashes
CHLAMYDIA
•Corneal scarring
TRACHOMATIS
•Blindness

EYELID •Stye
INFECTIONS
STAPH AUREUS
•Bilateral eye lid swelling

•Eosinophilis
•Muscle pain
•History of gi infection TRICHINELLA
•Unilateral inflammation at
bite site around eye or
mouth.
• History of travel TRYPANOSOMA CRUZI

Infectious
• What is the most important preventable cause
of blindness in the world?
TRACHOMA

EYE INFECTIONS: ON FUNDOSCOPY
FINDINGS ON FUNDOSCOPY KEY CLUE DIAGNOSIS
Chorioretinits Neonate
CMV
TOXOPLASMA
Retinopathy with keratitis in Mother has history of

TREPONEMA PALLIDUM
a newborn or a young child drug abuse or
CONGENITAL SYPHILLIS

Infection Key clue Causitive agent
Furuncles, Carbuncles Neck, Face, axillae, buttocks

S. AUREUS
From neck down

Has bath tub at home PSEUDOMONAS
Loves to play in the bath tub
Inflammation of Teenager PROPIONIBACTERIUM

sebaceous glands and ACNES
follicles
Patients presenting with cutaneous lesions
Mother brings a child •Initially vesicular
with cutaneous lesions. •Honey crusted lesion
Started from a bite of •Catalase negative S. PYOGENES
mosquito
•No pain, No systemic
Child kept on scratching.,
symptoms
•Initially vesicular
•Longer lasting and bigger S. AUREUS
bullae formation
•Catalase positive
Mother brings a child •Initially vesicular
with cutaneous lesions. •Honey crusted lesion
Started from a bite of •Catalase negative S. PYOGENES
mosquito
•No pain, No systemic
Child kept on scratching.,
symptoms
•Initially vesicular
•Longer lasting and bigger S. AUREUS
bullae formation
•Catalase positive
Mother brings her child On PE you see

with multiple infected multiple dry, heaped
wounds on the lower up tightly adherent
extremities. Mother states crusts
that the lesions started as ECTHYMA
mosquito bites and child S. PYOGENES
kept on scratching them.
PATIENTS PRESENTING WITH VESICULAR
LESIONS
Preceded with neurological

HERPES ZOSTER
pain
Very large bullous lesions.
Progressing rapidly.
Preceded by fever, fatigue, STAPHYLOCOCAL
SCALDED SKIN
malaise. Toxic looking patient. SYNDROME
Denuded areas.
Multiple vesicular lesions,

some papules, some crusted VARICELLA
all at different age
Patients presenting with cellulitis or subcutaneous inflammation
Inflamed Red, raised, butterfly rash

erythematous skin, in appearance with derma
ERYSEPELAS
tender and warm pain and rapid spread
S. PYOGENES
Following contact with

saltwater or oysters
VIBRIO VULNIFICUS
Burn patient
Blue-gree pus
Grape like odor PSEUDOMONAS

Patients presenting with lymphatic obstruction or lymphocutaneous lesions
Solitorary or lymphocutaneous lesions

Rose gardeners
Likes lying in the garden SPOROTHRIX SCHENKII
With history of painless genital ulcer LGV C. TRACHOMATIS L1-

L13
Fever, headache, elephantiasis of limbs
or genitalia
WUCHERERIA

Patients presenting with granulomatous lesions and draining sinut tract
Patients with granulomatous Jaw area swelling
lesions, draining sinus tract Sinus tract formation
Yellow exudate ACTINOMYCES ISRAELLI
Carious teeth
Dental procedure
Yelloe granules in exudate MYCOBACTERIUM
Tropical fish enthusiasts MARINUM
Subcutaneous swelling of
shoulder NOCARDIA
Sinus tract formations
granules
Usually in the cervical area TUBERCULOSIS
Child has chronic cough
Other cutaneous lesions
Malignant pustule Pustule to dark red fluid filled to
necrosis to black eschar CUTANEOUS ANTHRAX
Target lesion Fever headache

Bull’s eye Rashy border BORRELIA BURGDORFERI
Bite site LYME DISEASE
PATIENTS WITH INFECTED WOUND
Hx of animal bite
Cellulitis with lymphadenitis PASTEURELLA MULTOCIDA
Hx of Cat bite or Cat scratches

Or no history of bite but with pet kitty
Lymphadenopathy with stellate granulomas BARTONELLA HENSELAE
Hx of shallow puncture wound through

tsinelas or thru rubber shoes PSEUDOMONAS
Surgical wound clean

S. AUREUS
Surgical wounds dirty
S. AUREUS
trauma
CLOSTRIDIUM

Patients presenting with infectious arthritis
Pain All ages except
Redness between 15-40 S. AUREUS
Low grade fever
Tenderness joints 15-40 yo
Reduced mobility Sexually active GONOCOCCAL ARTHRITIS
promiscous
Prosthetic joint S. EPIDERMIDIS

Following GIT infection
few weeks ago
REITER’S SYNDROME
Patients presenting with osteomyelitis

FEVER Adults, children,
STAPH. AUREUS
Bone pain with infants without
swelling, redness major trauma or
Associated cellulitis special conditions
Neonates <1 month STAPHY AUREUS
old GBBS
Sickle cell anemia
SALMONELLA
History of trauma PSEUDOMONAS
Patient presenting with ear, nose, and throat infection
Acute otitis media Red, bulgin, tympanic

STREP. PNEUMONIAE
membrane, fever
H. INFLUENZAE
MORAXELLA CATARRHALIS
Sinusitis Sinus pain
Low grade fever (SIM)
Common cold Sneezing

Scratching throat RHINOVIRUS
Runny nose CORONAVIRUS

PATIENT PRESENTING WITH SORE THROAT
Inflamed tonsils or pharynx
Purulent STREP. PYOGENES
Fever
White papules with red base on posterior HERPANGINA
palate and pharynx COXSACHIE A
Purulent tonsils
Fatigue EBV
lymphadenopathy
Low grade fever with gradual onset of
membranous nasopharyngitis DIPHTERIA
Bull neck from lymphadenopathy C. DIPHTHERIAE
finely papular, erythematous eruption
producing a bright red discoloration of the
skin, which blanches on pressure. more
intense along the creases of the elbows,
axillae, and groin. The skin has a goose- STAPHYLOCOCCAL SCALDED SKIN
pimple appearance and feels rough.. After 4 SYNDROME
days, the rash begins to fade and is followed
by desquamation
PATIENTS PRESENTING WITH TOXIC LOOKING RASHES
Petechiae to purpuric Generalized

lesions Abrupt onset with feverl, chills, N. MENINGITIDIS
prostration, and shock
Fever
Headache
R. RICKETTSII
Rash that includes the palms and
soles
Fever
Headache R. PROWAZEKII
Rash that spares the palms and
soles
Erythematous Trunk and neck and then extremities
STREP. PYOGENES
maculopapular rash associated with sore throat and
Sand paper like fever
Diffuse erythematous Turnk and neck and then extremities TOXIC SHOCK SYNDROME
macular sunburn-like with desquamation on palms and STAPH AUREUS
rash soles
Acute onset of fever, pharynitis
Diarrhea
hypotension
CHILD PRESENTING WITH RASHES
cough coryza and conjunctivitis and
fever Measles/Rubeola
posterior cervical, cervical or

auricular nodes 3 Day/German Measle
slapped cheek looking then spread to

trunk with central clearing Fifth Disease
abrupt onset of fever with uri for 3-4
days, fever disappears and rashes
appears on trunk and spread Roseola
Preceded by rapid onset of fever,

myalgia, ocular pain, hyperthesia.
Rashes blanch on pressure. Dengue

Exanthems
Disease 1. Rubeola 2. Scarlet fever 3. Rubella 4. Duke’s 5. Erythema 6. Exanthem
Disease Infectiosum Subitum
AKA Measles Scarlatina German Variant of Slapped Cheek Roseola

measles/ 3day scarlet fever infantum/ 3
measles day fever
Cause Measles Group A (Strep Rubella Strep pyogenes PV-B19 HHV6,7
pyogenes)
Others Kopliks AURI Forchheimer Arthritis High fever

3 Cs spots Nagayama
OM – most Rashes spots
common Disappears as it Evanescent
Pneumonia - progress down Rash appears
death 5 days before once afebrile;
Branny 6 days after initally trunk
Desquamation
3days before
4-6 after
Complication Subsclerosing Congenital Aplastic anemia Convulsions –
Panencephalitis Rubella most common
(SSPE) Syndrome complication
Progressive
Rubella
Panencephalitis
(PRP)
Infectious
33. Which of the following statements is true
regarding measles?
a. Highly infectious 3 days before and 4-6 days after
the onset of rash
b. Pneumonia is the most common complication
c. Forrcheimer spot is usually seen in the soft palate
d. Branny desquamation is usually not seen

RHEUMATOLOGY
KAWASI DISEASE (Mucocutaneous Lymph Node
Syndrome)
• FEVER for at least 5 days and 4 of the following features:
– Conjunctivitis
• Bilateral, bulbar injection without exudate
– Rash
• Any form of rash
– Adenopathy
• Cervical adenopathy, non suppurative
– Strawberry tongue and other oropharyngeal changes

• Red cracked, swolle lips
– Hand changes
• Brawny edema, induration
• Peeling around the nail beds
Rheumatology
34. Most dreaded complication of Kawasaki
Disease
a. Myocarditis
b. Coronary artery aneurysm
c. Bleeding
d. Arrhythmia

Phase 1 Phase II Phase III
Acute Phase Subacute Convalescent
Phase Phase
DURATION 1-2 weeks 2-4 weeks Months to years
CLINICAL Fever and the other Defervesence of

MANIFESTATIONS acute signs of illness inflammation
peeling from nail
beds
LABORATORY Increased ECR and Decreased ESR Normalization of

FINDINGS Increased CRP Decreased CRP laboratory findings
Increased
Platelet count
TREATMENT IV IG LOW DOSE ASPIRIN
HIGH DOSE
ASPIRIN
HSP
• occurs worldwide and affects all ethnic groups
• affects males more than females, with a 1.2-
1.8 : 1 male: female ratio
• Approximately 90% of HSP cases occur in
children, usually between the ages of 3 and
10 yr
• follow a documented upper respiratory
infection
• Pathology - deposition of IgA, specifically IgA1
HSP
• Hallmark - rash: palpable purpura starting as pink macules
or wheals and developing into petechiae, raised purpura,
or larger ecchymoses.
• Occasionally, bullae and ulcerations develop.
• skin lesions - symmetric and occur in gravity-dependent
areas (lower extremities) or on pressure points (buttocks)
• The skin lesions often evolve in groups, typically lasting 3-
10 days, and may recur up to 4 mo after initial
presentation.
• Subcutaneous edema localized to the dorsa of hands and
feet, periorbital area, lips, scrotum, or scalp is also
common.

HSP
• Musculoskeletal involvement - arthritis and
arthralgias, in up to 75% of children
– arthritis tends to be self-limited and oligoarticular, with a
predilection for the lower extremities, and does not lead
to deformities. The arthritis usually resolves within 2 wk
but can recur.
• Gastrointestinal manifestations - up to 80% of
children with, include abdominal pain, vomiting,
diarrhea, paralytic ileus, melena, intussusception,
and mesenteric ischemia or perforation.

HSP
• Renal involvement - up to 50% of children:
hematuria, proteinuria, hypertension, frank
nephritis, nephrotic syndrome, and acute or chronic
renal failure. Progression to end-stage renal disease
is uncommon in children (1-2%)
• Neurologic manifestations - due to hypertension or
central nervous system (CNS) vasculitis. They include
intracerebral hemorrhage, seizures, headaches, and
behavior changes.
• Other less common potential manifestations of HSP
are orchitis, carditis, inflammatory eye disease,
testicular torsion, and pulmonary hemorrhage.

RENAL
ACUTE POST STREPTOCOCCAL GLOMERULONEPHRITIS
• Most commonly sporadic

– Serotype following throat infection ____
Serotype 12
– Serotype following skin infection_____

Serotype 49
• Clinical manifestation: patient develops

nephritic syndrome
– how many weeks after throat infection? 1-2 weeks
– How many weeks after skin infection? 3-6 weeks

ACUTE POST STREPTOCOCCAL GLOMERULONEPHRITIS
ABNORMALITY RESOLVE
Acute Phase
6-8 weeks
Urinary Protein Excretion

Hypertension 4-6 weeks
Microscopic hematuria 1-2 years
C3 level
6-8 weeks
Nephrology
35. Regarding PSGN, which of the following is
the last to resolve?
a. Hypertension
b. Edema
c. Microscopic hematuria
d. Proteinuria

PATIENTS PRESENTING WITH NEPHRITIC SYNDROME
CLINICAL HISTORY PHYSICAL EXAM DIAGNOSIS

VIGNETTE
Patient Presents with Normal on physical
presenting hemoptysis and examination
with severe Good Pasture’s
hematuria, respiratory syndrome
hypertension, distress
and signs of 3 weeks ago with Purpuric rash most
renal Systemic Viral prominent at the Henoch-Schönlein
insuffiency Illness buttocks Purpura Nephritis
Pain in the joints
Hx of vomiting, Dehydrated
and bloody hepatosplenomegaly
diarrhea and Hemolytic Uremic
fever Syndrome
Hx of eating
hamburger
PATIENTS PRESENTING WITH NEPHRITIC SYNDROME
CLINICAL VIGNETTE KEY CLUES LABORATORY DIAGNOSIS
Sudden onset of Patient is febrile Normal C3

gross hematuria with URT infection level IG A NEPHROPATHY
or GIT infection
History of strep Severely

throat or pyoderma depressed C3 POST STREPTOCOCCAL
level GLOMERULONEPHRITIS
Child discovered to •Patient wears very Normal labs

have asymptomatic thick glasses and
microscopic wears hearing aid
hematuria during •Child has uncles
ALPORT’S SYDNROME
yearly check up at with the same
school condition

Nephrology
36. Which of the following diseases is of
nephritic type?
a. Good pasture’s syndrome
b. Minimal change disease
c. FSGN
d. MPGN

NEPHROTIC SYNDROME
• Idiopathic Nephrotic Syndrome
– Minimal change disease
– Focal segmental glomerulosclerosis
– Mesangial proliferation
• Glomerular diseases
– Membranous nephropathy
– Membranoproliferative glomerulonephritis

NEPHROTIC SYNDROME
• The urinalysis reveals 3+ or 4+ proteinuria
• Spot urine protein/creatinine ratio exceeds 2.0
and urinary protein excretion exceeds 3.5 g/24 hr
in adults and 40 mg/m2/hr in children.
• The serum albumin level is generally <2.5 g/dL,
and the serum cholesterol and triglyceride levels
are elevated.
• C3 and C4 levels are normal.
• Renal biopsy is not required for diagnosis in most
children

NEPHROTIC SYNDROME
• The major complication of nephrotic
syndrome is __________
INFECTION
–The most frequent type of infection is

__________
SPONTANEOUS BACTERIAL PERITONITIS
–The most common organism causing

peritonitis is _____________ S. pneumoniae

ONCOLOGY
• Most common malignant neoplasm in childhood?
LEUKEMIA
• Most common cancer in adolescents?
LYMPHOMA
• Most common solid tumor?
BRAIN CANCER
• Most common solid tumor outside CNS?
NEUROBLASTOMA
• Most common soft tissue tumor?
RHABDOMYOSARCOMA
• Malignancy with highest mortality?
BRAIN CANCER
Oncology
37. What is the most common malignant
neoplasm in childhood?
a. Lymphoma
b. CNS tumor
c. Leukemia
d. Neuroblastoma

ACUTE LYMPHOCYTIC LEUKEMIA
SIGNS AND Anorexia, fatigue, and irritability, low-grade fever and
bone pain particularly in the lower
SYMPTOMS:
DIAGNOSIS BM biopsy/ BM aspiration

MOST IMPORTANT Response to treatment
PROGNOSTIC FACTOR
3 HIGH RISK •Age of diagnosis ( >10 years old)

PREDICTIVE FACTORS •Initial Leukocyte count (>50k)
•Speed or response to treatment

3 PHASES OF CANCER THERAPY
REMISSION INDUCTION CONSOLIDATION and MAINTENANCE

INTENSIFICATION
• ERADICATE • 14-18 weeks • 2-3 YEARS

LEUKEMIC CELLS IN • CNS THERAPY • MERCAPTOPURINE
THE BM • Prevent relapse in DAILY
• VINCRISTINE sanctuary sites • METHOTREXATE
• STEROIDS • Delayed WEEKLY
intensification

Oncology
38. Phase of cancer therapy that aims to prevent
relapse in sanctuary sites
a. Remission induction
b. Consolidation and Intensification
c. Maintenance
d. Reinduction

CANCER THERAPY
CLINICAL VIGNETTE DIAGNOSIS
Recurrent headache, nausea,
After completion and vomiting CNS RELAPSE
of cancer
Testicular pain and swelling
treatment, patient TESTICULAR RELAPSE
presents with joint pains, hematuria,
increasing lethary, emotional TUMOR LYSIS
disturbances, and acute SYNDROME
renal failure

BRAIN TUMOR
• The Childhood Brain Tumor Consortium reported a slight
predominance of
– Infratentorial tumor location (43.2%)
– Supratentorial location (40.9%)
– Spinal cord (4.9%)
– Multiple sites (11%).
AGE GROUP LOCATION TYPE
Birth to 1st year Supratentorial Choroid plexus complex

tumors and teratomas
1-10 years of age Infratentorial Juvenile pilocytic astrocytoma
After 10 years Supratentorial Diffuse astrocytoma

Oncology
39. True of CNS tumors in childhood
a. Majority are supratentorial
b. Infratentorial tumors present with the triad of
headache, Nausea/Vomiting, and papilledema
c. Juvenile pilocytic astrocytoma is the most
common supratentorial tumor
d. Infratentorial tumors are more commonly
associated with focal deficits than supratentorial
tumors

Oncology
40. Which of the following statements is not true of
neoplasms of the kidney?
a. Wilms Tumor is the most common primary malignat
renal tumor
b. The triad of Renal cell Ca are frank hematuria, flank
pain, and palpable mass
c. Clear cell sarcoma of the kidney has low metastatic
potential with predilection to invade the bone
d. Congenital mesoblastic nephroma is the most likely
diagnosis of a solid renal tumor in a neonate

CNS
CSF FINDINGS
PRESSURE CELL COUNT PROTEIN GLUCOSE OTHERS Agent
(50-80) <5, >75 L 20-45 >50mg/dl
75% of
Serum
Acute bacterial
PMNS meningitis
N LYMPHOCYTES
N Viral
meningoencephalitis
LYMPHOCYTES AFB Tuberculous meningitis
negative
LYMPHOCYTES India Ink
Positive Fungal meningitis
Hanging
PMNS drop test Amoebic meningitis
positive
Partially treated
N PMNS N
herbert-leonides c. garcia, m.d. bacterial meningitis
Neurology
41. Which type of meningitis is exemplified by
the following CSF picture: Low sugar, high
protein, high CSF pressure with predominance
of lymphocytes on cell analysis
a. Bacterial meningitis
b. Viral meningitis
c. TB meningitis
d.Fungal meningitis

Neurology
42. Most common complication of streptococcal
meningitis
a. Sensory neural hearing loss
b. Mastoiditis
c. Cerebral palsy
d. Epilepsy

Patient presenting with CNS Infections
Sepsis, seizure, Patient is less than 2 months old
1. GBBS
irritability, lethargy,
bulging of
2. E.coli
fontanelles, rigidity
Heahache, fever, No mention of proper vaccination
confusion, lethargy, Less than 5 years old H. influenza
nuchal rigidity,
vomiting Properly vaccinated child
Abrupt in onset
Toxic looking with rashes all over N. meningitidis
Adolescents living in dormitories
Young adults S. pneumoniae
Renal transplant patient
L. monocytogenes
Gradual onset of signs and symptoms not

toxic looking Enterovirus
RBC’s in the CSF examination

HSV encephalitis
CNS Infections
43. Adolescent patient, living in a dormitory,
suddenly developed headache, fever and
changes in sensorium. What is the most likely
pathogen?
a. Hib
b. Neisseria meningitides
c. Streptococcus pneumonia
d. Listeria monocytogenes

Seizures
• Focal vs Generalized
• Absence
• Tonic
• Clonic
• Tonic-Clonic
• Myoclonic
• Epilepsy
>2 unprovoked seizures occurring in a time
frame of >24hours

Seizures
FEBRILE SEIZURE
• the most common seizure disorder during childhood
• 6-60 months of age
• usually associated with a core temperature of ≥38°C.
• It is initially generalized and tonic-clonic in nature, lasts a few seconds and rarely
up to 15 min, is followed by a brief postictal period of drowsiness, and occurs only
once in 24 hr.
COMPLEX OR COMPLICATED
• when the duration is >15 min
• when repeated convulsions occur within 24 hr
• when focal seizure activity or focal findings are present during the postictal period.
STATUS EPILEPTICUS
– one seizure lasting 30 min or multiple seizures during 30 min without
regaining consciousness
– is often due to central nervous system infection

Neurology
44. True of seizures
a. Focal seizures involve both cerebral hemispheres
b. Epilepsy is > 2 unprovoked seizures occurring in a
time frame of >24hours
c. Clonic seizures are characterized by increased
tone or rigidity
d. Febrile seizure is a primary focal tonic-clonic
seizure associated with fever lasting for a maximum
of 15 minutes

FLUIDS AND
ELECTROLYTES
Composition of Body Fluids

Compartments of TBW

Compartments of TBW
PLASMA
• Blood volume – 8 %
• Altered by
– Dehydration, anemia, polycythemia, heart failure, hypoalbuminemia
INTERSTITIAL FLUID
• Increased in:
– Edema, heart failure, protein losing enteropathy, liver failure,
nephrotic syndrome, sepsis, pleural effusion, ascites
HYDROSTATIC PRESSURE – ONCOTIC PRESSURE

Lymphatics

Electrolyte Composition

Electrolyte Composition
• Anions
– Affected by intracellular molecules and cell membrane
• Cations
– Na+ , K+ - ATPase pump
• Osmolality
– Osmotic Equilibrium
– 285-295 mOsm/kg
– 2Na + (glucose/18 )+ (BUN/2.8)
– Effective osmolality (tonicity)
– Measured osmolality vs calculated osmolality  10 mOsm/kg
– Unmeasured osmoles – ethanol, ethylyn glycol, methanol, mannitol
– Osmolal gap
– Hyperglycemia, Pseudohyponatremia

Regulation of Osmolality and Volume
• Water balance determines osmolality
• Sodium balance determines volume status
• Volume regulation takes precedence over
osmolality regulation
• Water intake and production = losses

Sodium
• Dominant ECF cation; concentration determined by water balance
• Principal determinant of extracellular osmolality
• <3% intracellular, >40% in bone, remainder in the ECF
• Intake
– Determined by Diet
– Breastmilk 7meqs; formula 7-13meqs
– Recommended intake < 2500mg/day
– Readily absorbed throughout the GIT
– Glucose enhances absorption
• Excretion
– Kidney is the principal site, dependent on plasma osmolality
– Stool, sweat

Hypernatremia
• Na > 145meqs/L
• Causes:
– Excessive sodium
• Improperly mixed formula, Excess NaHCO3, Ingestion of
seawater or NaCl, Intentional salt poisoning, IV hypertonic
saline, Hyperaldosteronism
– Water deficit
• Diabetes insipidus (Central/nephrogenic), increased sensible
losses, inadequate intake
– Water and Na deficit
• Gastrointestinal losses (diarrhea/emesis/osmotic cathartics),
cutaneous losses (burns/excessive sweating), renal losses
(osmotic diuresis, DM, CKD, ATN)

Hypernatremia
Clinical Manifestations:
– Hypernatremic dehydration
• Better preservation of intravascular volume
• Less symptomatic initially
• Potentially more dehydrated on consult
• Pinched abdominal skin - “doughy” feel
– CNS symptoms parallel Na increase and acuity
• Irritable, restless, weak, lethargic, high pitched cry, hyperpnic, thirsty
– May cause fever
– Brain hemorrhage
– Seizure/Coma
– Central pontine myelinolysis(CPM)/Extra pontine myelinolysis
– Thrombotic complications

Hypernatremia
Diagnosis
• History/PE
• Severe Na intoxication/ Salt poisoning
– Sx of volume overload (pulmonary edema, wt gain)
– Elevated fractional excretion of Na
• Hypernatremic DHN
– Low excretion of Na
Cause Urine Output Urine Conc. Urine Na
Renal ↑ ↓ ↑
Extrarenal ↓ ↑ ↓
• Tests: ADH, water deprivation test, Trial of desmopressin acetate

Hypernatremia
• Treatment
– Idiogenic osmoles
– Rapid correction  seizure/coma except acute cases
– Goal: ↓Na <12meqs/L q24°, rate of 0.5meqs/L/hr
– Most important component: frequent Na monitoring
– 1st priority: restoration of volume w/ isotonic fluid
• Water deficit = BW x 0.6 (1-145/[current Na])
– Options:
• Peritonial dialysis
• Loop diuretics
• Na free IVF
• ORS
– Don treat hyperglycemia
– Treat hypocalcemia as needed
– Treat underlying cause
Hyponatremia
• Serum Na <135 mEq/L
• Ratio of H2O to Na is ↑
• Body Na – low, normal, high
• Body H2O – low, normal, high
• Causes:
– A. Pseudohyponatremia: due to hyperosmolality (hyperglycemia,
Mannitol/Sucrose, Hypovolemic Hyponatremia
– B. Extrarenal losses: emesis, diarrhea, sweating, burns
– C. renal losses: diuretics, ATN, PCKD, CAH
– D. Euvolemic Hyponatremia: SIADH,water intoxication,
glucocorticoid deficiency
– E. Hypervolemic hyponatremia: CHF, nephrotic syndrome, cirrhosis,
RF, protein losing enteropathy

Hyponatremia
• Classification is based on pt’s volume status
• Hypovolemic hyponatremia – Na loss is > water loss
– Diarrhea (50mEq/L), emesis, burns, CF, aldosterone deficiency
• Hypervolemic hyponatremia - ↑TBW and Na, H2O > Na
– ↓ EBV ← 3rd space loss, vasodilation, poor CO
– Renal failure
– ↓ urine Na (<10 mEqs)
• Euvolemic hyponatremia- ↑TBW, ↓Na
– SIADH
• Water retention  ↑ IV volume  Dilution of serum Na  ↑ Na
excretion
• CNS, Lungs, Tumors, Medications
• ↓ uric acid and BUN are supportive of the diagnosis

SIADH
• Diagnostic Criteria
– Absence of:
• Renal/adrenal/thyroid insufficiency
• Heart failure, nephrotic syndrome or cirrhosis
• Diuretic ingestion
• dehydration
– Urine osmolality > 100 mOsm/kg (usually > plasma)
– Serum osmolality <280 mOsm/kg and serum Na <135mEq/L
– Urine Na >30 mEq/L
– Reversal of sodium wasting and correction of hyponatremia with
water restriction
– Nephrogenic SIADH – x-linked DSO appear to have SIADH but have

undetectable levels of ADH

Hyponatremia
• Hospitalized patients – inappropriate production
of ADH and administration of hypotonic fluids
– Stress, medications, nausea, respiratory illness
– Desmopressin acetate – central DI, Nocturnal
enuresis
• Excess water ingestion
– 2° to dilution
– Intake exceeds kidney’s ability to eliminateH2O
– Common in infants

Hyponatremia
• Dangerous for the brain  brain swelling
• ↑ ICP
• Impairs cerebral blood flow
• Can cause brainstem herniation/apnea
• Symptoms:
– Anorexia, nausea, emesis, malaise, lethargy,
confusion, agitation, headache, seizures, coma, ↓
reflexes, hypothermia, muscle cramps, weakness
– Dependent on serum Na level and rate of decrease

Potassium
• 150mEq/L intracellularly, majority in muscles*
• Extracellularly in bones, <1% in plasma
• Maintained by Na+,K+-ATPase
– Insulin, Epinephrine, Acid base imbalance, α & β
adrenergic agonists, Exercise, plasma osmolality
• Necessary for resting membrane potential, electrical
responsiveness of nerve/muscles, contractility
• 1-2 mEq/kg recommended intake
• 90% absorbed in the small intestine
• Exchanged for Na in the colon

Potassium
• Excretion
– Sweat
– Colon
– Cellular uptake
– Urine
• Freely filtered in the glomerulus , 90% resorbed in the DT
and CD
• Aldosterone – principal regulator
– Glucocorticoids, ADH, high urinary flow rate, high Na level in
the CD
• Excretion decreased by:Insulin, Cathecolamines, Urinary
ammonia

Hyperkalemia
• Causes:
– A. Spurious laboratory value (hemolysis, tissue ischemia on
extraction, thrombocytosis, leukocytosis, delay/storage)
– B. Increased Intake (IV or oral, BT)
– C. Transcellular shifts (acidosis, rhabdomyloysis, tumor lysis
syndrome, tissue necrosis, hemolysis/hematoma,
Succinylcholine, Digitalis, β blockers, exercise,
hyperosmolality, insulin deficiency, malignant hyperthermia,
hyperkalemic periodic paralysis
– D. Decreased excretion (renal failure, Adrenal disease, ACE
inhibitors, ARB, K sparing diuretics, NSAIDS, TMP, Heparin)

Hyperkalemia
• Clinical Manifestations
– Cardiac conduction system
• Peaking T waves  ST segment depression  ↑PR interval  P wave
flattening  QRS complex widening
– Ventricular fibrillation
– Asystole
– Parethesias
– Fasciculations
– Weakness
– Ascending paralysis
– Cardiac toxicity usually precedes clinical symptoms
– Absence of symptoms DOES NOT imply absence of danger
– Chronic hyperkalemia better tolerated

Hyperkalemia
• Treatment
– K level, ECG, risk of progression determines approach
– Stop all sources
– Washed RBC for BT
– >6-6.5 mEq/L  ECG
– 2 basic goals:
– 1. stabilize heart to prevent arrythmias
• Ca
• Bicarbonate
• Insulin
• Nebulized Albuterol
– 2. remove K from the body
• Loop diuretic
• Na polystyrene sulfonate (Kayexalate)
• Dialysis

Hypokalemia
• Common in children, most cases related to AGE
• Causes:
– 1. Spurious (high WBC count)
– 2. Transcellular shifts (Alkalemia, Insulin, β adrenergic
agonists, Theophylline, Barium, Toluene, hypokalemic
periodic paralysis, thyrotoxic period paralysis, refeeding
syndrome
– 3. Decreased intake (anorexia nervosa)
– 4. Extrarenal losses (diarrhea, laxative abuse, sweating,
Kayexalate , clay ingestion)
– 5. Renal losses (RTA, DKA, ATN, Post obstructive diuresis,
diuretic use, Bartter/Gitelman syndromeRenovascular
disease, renin secreting tumors, Cushing syndrome

Hypokalemia
• ECG changes:
– Flat T waves, depressed ST segment, U wave
• Ventricular fibrillation/SVT/V tach/Heart block
• Muscle weakness/cramps
• Paralysis (muscular/respiratory)
• ↓GI motility/bladder function
• Poor linear growth

Hypokalemia
• Treatment
– Factors to consider: Potassium level, clinical symptoms, Renal
function,presence of transcellular shifts, ongoing losses, and
the patient’s ability to tolerate oral potassium
– IV potassium should be used cautiously
– Oral: 2-4 mEq/kg/day with a maximum of 120-240 mEq/day
in divided doses
– IV: 0.5-1 mEq/kg, given over 1 hour
– KCl is the usual choice
– If with acidosis, potassium acetate or citrate
– If with hypophosphatemia, potassium phosphate
– If with hypokalemia, metabolic alkalosis and volume
depletion, restore volume with NaCl
Magnesium
• 50-60% is in bone
• NV: 1.2-1.9 mEq/L
• Important for membrane stabilization and nerve
conduction
• Cofactor for hundreds of enzymes (ATP/GTP)
• Sources: vegetables, cereals, nuts, meats
• Absorption: 30-50%; decreased if with free fatty acids,
fiber, phytate, phosphate, oxalate, increased intestinal
motility, calcium; increased by Vit. D and PTH
• Renal excretion is the principal regulator of balance

Hypomagnesemia
• Causes: GIT disorders, renal disorders, poor intake,
Insulin administration, pancreatitis, Exchange
transfusions, hungry bone syndrome, refeeding
syndrome
• Manifestations: causes secondary hypocalcemia
leading to tetany, (+)Chvostek and Trosseau signs;
also associated with hypokalemia
• ECG: T wave flattening, ST segment lengthening
• Treatment: Magnesium sulfate 25-50mg/kg (0.05-
0.1 ml/kg, 50% solution) via slow IV infusion/IM,
repeated q6° for 2-3 doses
Hypermagnesemia
• Almost always 2° to excessive intake
• In neonates – mothers receiving IV magnesium
• Excessive use of antacids/laxatives, DKA,
lithium, tumor lysis syndrome
• Symptoms: hypotonia, hyporeflexia, weakness;
paralysis at high concentrations; CNS
depression; hypotension; CHB/cardiac arrest
• Treatment: IV hydration, loop diuretics, dialysis,
exchange transfusion
Phosphorus
• 65% is in phospholipids in
bones/intracellularly but unmeasurable
• Phosphorus content of plasma phosphate that
is determined
• Critical for cellular energy metabolism, nucleic
acid synthesis, component of cell membranes
• Milk and milk products are the best sources
• Absorption: small intestine, regulated by Vit. D
Hypophosphatemia
Causes: Insulin release, glycolysis, DKA, refeeding
syndrome, antacids, hyperparathyroidism,
diuretics, vitamin D deficiency, tumors
• Acute: rhabdomyolysis, decreased cellular energy,
hypoxia, hemolysis
• Chronic: rickets, proximal muscle weakness
• Treatment:
– Oral: causes diarrhea, should be divided
– IV: severe deficiency, unable to tolerate oral
Hyperphosphatemia
• Renal insufficiency most common cause
• Transcellular shifts (tumor lysis syndrome,
rhabdomyolysis, acute hemolysis), increased
intake (laxatives, vitamin d intoxication),
decreased excretion (hypoparathyroidism,
acromegaly, hyperthyroidism)
• Causes hypocalcemia and systemic calcification
• Treatment: IVF, oral binders, calcium carbonate,
diet restriction, dialysis
Fluids and Electrolytes
• Maintenance intravenous fluids - used in a
child who cannot be fed enterally.
• replacement fluids - if they have continued
excessive losses, such as may occur with
drainage from a nasogastric (NG) tube or with
high urine output due to nephrogenic
diabetes insipidus
• deficit replacement - If dehydration is present

Maintenance therapy
• most commonly necessary in preoperative
and postoperative surgical patients; many
nonsurgical patients also require maintenance
fluids
• It is important to recognize when it is
necessary to begin maintenance fluids

Maintenance therapy
• Goals:
– Prevent dehydration
– Prevent electrolyte disorders
– Prevent ketoacidosis
– Prevent protein degradation
– contain D5, which provides 17 calories/100 mL and

nearly 20% of the daily caloric needs
– This level is enough to prevent ketone production and
helps minimize protein degradation, but the child will
lose weight on this regimen

In all children, it is critical to carefully monitor weight, urine output, and
electrolytes to identify overhydration or underhydration, hyponatremia, and
other electrolyte disturbances, and to then adjust the rate or composition of
the intravenous solution accordingly.
Replacement therapy
• The gastrointestinal (GI) tract is potentially a source of
considerable water loss
• In the absence of vomiting, diarrhea, or NG drainage,
GI losses of water and electrolytes are usually quite
small
• All GI losses are considered excessive, and the increase
in the water requirement is equal to the volume of
fluid losses
• Replace excessive GI losses as they occur
• The losses are usually replaced every 1-6 hr, depending
on the rate of loss, with very rapid losses being
replaced more frequently

Deficit Therapy
• Dehydration, most often due to gastroenteritis, is a
common problem in children. Most cases can be managed
with oral rehydration
• Even children with mild to moderate hyponatremic or
hypernatremic dehydration can be managed with oral
rehydration
• The first step in caring for the child with dehydration is to
assess the degree of dehydration which dictates both the
urgency of the situation and the volume of fluid needed
for rehydration
• The history is most helpful
• fluid deficit - % of dehydration x patient's weight e.g. 10
kg and is 10% dehydrated has a fluid deficit of 1 L

Approach to dehydration

WHO ORS MODIFIED
SOLUTION WHO ORS
SOLUTION
Na 90 75
Glucose 111 75
Potassium 20 20
Cloride 80 65
Citrate 10 10
Total OSmolarity 311 245

26. Regarding modified WHO ORS, which of the
following are properly paired?
• a. Na – 90
• b. K – 65
• c. Cl – 75
• d. Glucose – 75

45. Regarding fluids, which are properly paired?
a. Premature infants – lower TBW than term infants
b. Males – 50% TBW
c. Newborn – ECF volume higher than ICF
d. Post pubertal males and females – equal ICF

46. Maintenance Fluids containing D5 usually
provide how many calories per 100ml?
a. 15 calories
b. 17 calories
c. 20 calories
d. 25 calories

47. Which of the following causes decreased
water needs?
a. Phototherapy
b. Diarrhea
c. Polyuria
d. Hypothyroidism

48. Which type of dehydration is the most
dangerous?
a. Hyponatremic DHN
b. Eunatremic DHN
c. Hypernatremic DHN

LEARNING
DISORDERS
ADHD
• most common neurobehavioral disorder of
childhood
• among the most prevalent chronic health
conditions affecting school-aged children
• the most extensively studied mental disorder of
childhood
• characterized by inattention, including increased
distractibility and difficulty sustaining attention;
poor impulse control and decreased self-
inhibitory capacity; and motor overactivity and
motor restlessness

ADHD
Diagnosis
• the behavior must be developmentally
inappropriate (substantially different from that of
other children of the same age and
developmental level)
• must begin before age 7 yr
• must be present for at least 6 mo
• must be present in 2 or more settings, and
• must not be secondary to another disorder

Dyslexia
• characterized by an unexpected difficulty in reading in
persons who otherwise possess the necessary intelligence
and motivation that should permit accurate and fluent
reading
• the most common of the learning disabilities, affecting at
least 80% of children identified as manifesting learning
disabilities.
• In attempting to read aloud, most children and adults with
dyslexia display an effortful approach to decoding and
recognizing single words
• persons with dyslexia typically possess the vocabulary,
syntax, and other higher-level abilities involved in
comprehension

Dysfluency (Stuttering, Stammering)
• involves involuntary frequent repetitions, lengthenings
(prolongations) or arrests (blocks, pauses) of syllables,
or sounds that are exacerbated by emotionally or
syntactically demanding speech
• WHO definition - a disorder in the rhythm of speech in
which the person knows precisely what he or she
wishes to say but at the same time may have difficulty
saying it because of an involuntary repetition,
prolongation, or cessation of sound
• Stuttering often leads to frustration and avoidance of
speaking situations. Stuttering can lead to being bullied
or teased and to speech-related anxiety and social
phobia

Intellectual disability
• formerly called mental retardation
• refers to a group of disorders that have in
common deficits of adaptive and intellectual
function and an age of onset before maturity
is reached
• 3 criteria: 1. significantly subaverage
intellectual function, 2. significant
impairments in adaptive function, and 3.
onset before 18 years of age

Intellectual Disability

Autistic DSO
• core features: impairments in 3 symptom
domains:
a) social interaction;
b) communication; and
c) developmentally appropriate behavior,
interests, or activities

Learning Disorders
49. Most common neurobehavioral DSO of
childhood
a. ADHD
b. Autism
c. Intellectual Disability
d. Dysfluency

Learning Disorders
50. Not characteristic of ADHD
a. Inattention
b. Poor impulse control
c. Motor overactivity/restlessness
d. Lacks eye contact

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Post Graduate Interns Review

Veterans Memorial Medical Center

Herbert-Leonides C. Garcia, M.D.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

• Results from deposition of unconjugated

• Kernectirus is rare in healthy infants if the

herbert-leonides c. garcia, m.d.

First born child

Second born Child

History of prolonged second stage

History of maternal infection during

herbert-leonides c. garcia, m.d.

2-3 days Baby otherwise normal PHYSIOLOC

3-4 days Mother has inadequate

> 1 week Baby is purely breast fed

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

A newborn presents with Baby is 3 days old

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

DPT 6 wks 3 4 weeks IM

OPV/IPV 6 wks 3 4 weeks IM/Oral

HEPA B Birth 3 4 weeks IM

MEASLES 9 mos 1 n/a SQ

MMR 15 mos 1 n/a SQ

herbert-leonides c. garcia, m.d.

Flu 6 months 2 4 weeks IM/SQ

Typhoid 2yo 2 years IM

Meningo 9 mos/2yo 1/2 IM

Rotavirus 1/5 6 weeks 2/3 4 weeks Oral

Rabies Pre-ex 3 0,7,21/28 IM/ID

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

Iron Condition Dose

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

Vitamins Higher Vit A, B3, C, D, E Higher B1, B2, B6,

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

14. True of complementary feeding

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.

herbert-leonides c. garcia, m.d.