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Pediatrics Notes
Pediatrics Notes
Supportive
incubation 10-21d
- Antipyretics, daily bathing Progressive varicella:
prodrome: fever, malaise, anorexia,
meningoencephalitis,
Primary infection with VZV morbilliform rash Clinical diagnosis
Administer VZV vaccine within 72h of hepatitis, pneumonitis in
next day: pruritic rash on trunk, spreading - Tzanck smear
Varicella exposure immunocompromised
fatal disseminated disease peripherally. - DFA, viral culture,
in immunocompromised - red papules --> clear vesicles (dewdrop PCR
Acyclovir/valacyclovir/famciclovir not Reye syndrome if
on rose petal) --> crusts
indicated for children with taking aspirin
- occurs in crops
uncomplicated primary varicella
Pain/pruritus
Reactivation of VZV from Vesicular eruption in crops, confined to Antivirals for immunocompromised,
dorsal root ganglia dermatome pts >12 yrs, children with chronic
Herpes zoster
- clears up in 7-14d disease, and those who have
Uncommon in children <10 Pain persists for wks-months received systemic steroids
(postherpetic neuralgia)
Poxvirus Small, flesh colored, pearly, umbilicated,
Molluscum dome-shaped papules in moist areas Curretage, cryotherapy, cantharidin,
contagiosum Common in childhood, - axilla, buttocks, groin PO cimetidine, imiquimod cream
wrestlers, sauna bathers - resolve in 1-2 yrs
Topical salicylic acid, liquid nitrogen,
HPV Verruca vulgaris: common wart
imiquimod cream, PO cimetidine, PO
Verruca plantaris: plantar wart
Verrucae zinc sulfate, injected
Spread by skin-skin contact Verruca plana: flat wart
immunotherapies (candida antigen),
or fomites Condylomata accuminata: genital wart
squaric acid dibutylester
Presumed viral exanthems
Viral URI prodrome sometimes
Rash begins as herald patch, 2-10cm oval Self limited
salmon plaque on trunk, neck, UE, or Antihistamines, topical steroids for
Pityriasis Rosea
thigh --> smaller lesions in christmas tree pruritis
pattern over trunk and UE. sunlight
- fades over 4-12 wks
2
Unilateral thoracic
Exanthem on one side of trunk that spread
exanthem
centripetally Self limited - 6-8 wks
(asymmetric Children 1-5 yrs Often confused with
- variable: erythematous macules/papules Antihistamines, topical steroids for
periflexural Winter and spring contact dermatitis
with surrounding halo, morbilliform, pruritis
exanthem of
eczematous, scarlatiniform, reticulate
childhood)
Skin manifestations of bacterial infections
red macules --> bullous (fluid filled)
eruptions on erythematous base
Can be mistaken for
Bullous impetigo S. aureus toxin
cigarette burns
S. aureus can be cultured from vesicle
fluid
Limited: Muciprocin ointment
Numerous: cephalexin (1st gen)
papules --> vesicles --> 5mm pustules -->
- covers staph and strep
rupture --> honey colored crust over
group A beta hemolytic Suspect MRSA: clindamycin or TMP-
Nonbullous impetigo ulcerated base
strep, s. aureus SMX
Organism can be isolated from lesions
Remove honey colored crusts with
warm compress
3
Polycyclic urticaria:
can appear
Erythematous macules, papules, plaques, targetoid, but
Acute, self limited vesicles, target lesions lesions are not fixed
hypersenitivity reaction - evolve over days and do not have
PO antihistamines, moist
Erythema multiforme - herpesvirus, adenovirus, - fixed, develop necrotic centers necrotic centers.
compresses, oatmeal baths
EBV - dorsum of hands and feet, palms and Edematous,
- recurrent EM: HSV 1 soles, extensor surfaces, may spread to erythematous
trunk borders with central
clearing, resolving in
12-24 hrs
Hospitalization, fluid and electrolyte
Prodrome 1-14d: fever, malaise, myalgias,
10% mortality if untreated support, moist compresses, oatmeal
arthralgias, HA, emesis, diarrhea
baths
Sudden onset fever, erythematous
Stevens Johnson NSAIDs, penicillins,
purpuritic macules with duscky centers,
syndrome sulfonamides, antiepileptic Oral mucosal: mouthwashes with
inflammatory bullae of mucous
meds, mycoplasma, lidocain, diphenhydramine, Maalox
membranes
immunizations
- GI, resp, GU tract involvement if severe
Ophthalmology consult
Severe form of SJS
Positive Nikolsky sign Fluid therapy, treat like a burn
involving 30% of body
Toxic epidermal
30% mortality if untreated
necrolysis Elevated liver enzymes, renail failure, fluid IVIG: may affect binding/effect of Fas
Upregulated expression of
and electrolyte imbalance ligand
Fas-ligand in epidermis
4
Pulmonology
Condition Definition Epidemiology Etiology Signs/symptoms Ddx Treatment Complications High Yield facts
Obstructive lung diseases
Pickwickian Restless sleep with position Polysomnography: measure severe OSA --> CHF, death
Changes in upper airway
Obstructive sleep syndrome: OSA changes, irregular snoring, respiratory muscle activity, air flow, Pickwickian syndrome: chronic
tone during sleep, anatomic Remove tonsils/adenoids, CPAP
apnea associated with daytime somnolence, poor oxygenation, sleep stage, and heart hypoventilation results in pulmonary
obstruction
obesity growth, enuresis rate hypertension and CHF
Tracheal cartilage
rings that completely "washing machine" inspiratory
Congenital tracheal encircle trachea and and expiratory noise, hypoxemia,
stenosis grow more slowly failure to thrive
than the rest of
trachea
Loud, single S2
Parallel systemic and pulm circuits
VSD +/- pulm stenosis: systolic murmur
- Most common form of cyanotic CHD
PGE1
in first 24 h of life
CXR: mild cardiomegaly, incr pulm vascularity. "egg- Balloon atrial septostomy (Rashkind
D-transposition of - patent foramen ovale required to
shaped silhouette" procedure)
great arteries mix circuits
- ant aorta superimposed on posterior pulm artery results - enlarge PFO, incr atrial level mixing
- intact ventricular septum (60%),
in narrower mediastium Arterial switch procedure
VSD (30%), VSD + pulm stenosis
(10%)
ECG: R. ventricular hypertrophy
PGE1
No corrective surgery available - only
Neonates: severely decr systemic blood flow when PDA
palliative
closes. Shock, tachycardia, tachypnea
Atresia/hypoplasia of mitral valve
Aortic atresia or stenosis First week:
Right ventricular heave
PDA - connect pulm artery and aorta
Single S2
Hypoplastic left PFO with L-->R shunt - atrial septectomy
Continuous PDA murmur
heart syndrome - connect R. ventricle to pulm artery
Decr blood flow through left heart. (modified blalock-taussig)
CXR: pulmonary edema and cardiac enlargement
Systemic blood flow is completely 3-6 months:
PDA dependent - cavopulmonary anastamosis (hemi
ECG: R. ventricular hypertrophy, poor R wave
Fontan)
progression
2-5 years:
- modified Fontan
Paradoxical embolism
SVT from atrial enlargement
Ostium secundum: midportion
Ostium primum: lower septum
Systolic ejection murmur in pulmonic area (pulmonary
Sinus venosus defect: Junction of R.
Atrial septal valve), middiastolic rumble in lower right sternal
atrium and SVC/IVC
defect border (tricuspid valve)
Loud S1, fixed widely split S2
L-->R shunt: R. atrial and R.
ventricular enlargement
CXR: enlarged heart and main pulmonary artery
ECG: R ventricular enlargement
Condition Description Etiology Signs/symptoms Ddx Treatment Complications High Yield facts
C. trachomatis: afebrile,
conjunctivitis, staccato cough
M pneumo and C. pneumo:
f/HA/myalgia If pleural effusion: drain, cell count,
High dose amoxicillin or Pleural effusion -->
M pneumo: gram stain, culture
amox/clav for most bacterial compromise respiratory effort.
macular/erythematous rash,
Young children: pna. Erythromycin/azithromycin/ Chest tube Cold agglutinin titers
erythema multiforme If high fever in child: blood culture
viruses MCC clarithromycin for M pneumo or - most large pleural effusions are elevated in M.
acute inflammatory process
Pneumonia C. trachomatis at 2-3 C pneumo. are caused by s. aureus pneumo, many viral
occuring in lungs Viral: diffuse wheezing and rapid influenza test,
mo Azithromycin/Erythromycin for C. pneumonia and some bacterial
crackles DFA/PCR/tissue culture for C.
S. pneumo, etc trachomatis pneumonias
Bacterial: focal crackles/decr trachomatis
Neonates: ampicillin and Lung abscesses due to
percussion/egophony/bronchoph
cefotaxime (or gentamicin) anaerobic infections
ony M pneumo: PCR or cold agglutinins
Trichomonas: most
asymptomatic, malodorous,
frothy gray discharge and vaginal Trichomonas: PMNs and
discomfort. Penile discharge trichomonads on wet prep
Candida occurs in women
Trichomonas: PO metronidazole
with abx use, pregnancy, Candida,
Bacterial: thin, white, foul- Bacterial: vaginal pH > 4.5, clue Bacterial: PO metronidazole
Vulvovaginosis diabetes, Trichomonas,
smelling discharge with fishy cells Candida: antifungal creams or
immunosuppression, OCP bacterial
odor when mixed with KOH single dose of PO fluconazole
use
Candida: yeast and pseudohyphae
Candida: thick white vaginal on wet prep with KOH
discharge with vaginal itching
and burning
Fever, HA, rash 7d after tick bite No reliable diagnostic test. Abs
- f/c/HA/n/v/myalgias confirm diagnosis 10d after sxs Empiric rx - need to cover
- rash on 2nd-5th day, blanching erlichiosis and N. meningitidis
Tick bite (wood tick, dog
Rocky Mountain erythematouc macular lesions Thrombocytopenia and
tick, lone star tick) Rickettsia rickettsii
Spotted Fever that prgress to petechiae or hyponatremia doxycycline
April-Sept
purpura add cefotaxime or ceftriaxone if
- starts on wrists/ankles and Ddx: erlichiosis, meningococcemia, suspecting meningococcemia
spreads inward atypical measles
Risk factors: extended exclusive Mild (6-8 g/dL): decr appetite, irritability, fatigue, decr
breastfeeding (>6 mo), low-iron formula, exercise tolerance. Skin/mucous membrane pallor,
Iron supplement: reticulocyte count incr
low-iron solids, excessive cow milk. tachycardia, systolic ejection murmur along left sternal
within 3d, Hb concentration normalizes
Iron deficiency border Response to appropriate iron
within a month. Continue therapy for 2-3
anemia Occult blood loss: GI anomalies (meckel, supplementation is best diagnostic test
mo to replenish stores and prevent future
juvenile polyps) Severe (<3 g/dL): CHF, tachycardia, S3 gallop,
occurrence.
Overt loss: bloody stools or traumatic cardiomegaly, hepatomegaly, distended neck veins, rales
hemorrhage
Glossitis, angular stomatitis, koilonychia in children with
isolated iron def anemia in developed nations
Inflammation --> incr hepatic production TIBC low, ferritin normal or incr
of hepcidin -->
Anemia of internalization/degradation of ferroportin Mild anemia (8-10 g/dL) BM exam: Incr in storage iron, decr in iron-
Treat underlying inflammation
inflammation --> impaired release of iron from containing erythroblasts
macrophages and absorption of iron
from gut Usually normocytic initially
Nonmegaloblastic macrocytic anemias
Presents in first year of life.
Congenital pure red cell aplasia Macrocytosis, reticulocytopenia PO corticosteroids
Diamond-Blackfan
mutation in ribosomal protein S19 elevated HbF BM transplant
Anemia 25% have associated anomalies: short stature, web neck,
(RPS19) Elevated RBC adenosine deaminase
cleft lip, shield chest, triphalangeal thumb
Macrocytosis
RBC transfusions
Elevated HbF
Hematologic improvement with androgen
Hyperpigmentation, café au lait spots, microcephaly, 10% develop leukemia
AR or X linked, pancytopenia therapy
Fanconi anemia microphthalmia, short stature, horseshoe/absent kidney,
Defect in DNA repair SC transplant
absent thumbs Confirm diagnosis by demonstrating
- decrease doses of radiation/chemo bc
increased chromosomal breakage with
they damage DNA
exposure to diepoxybutane (DEB)
Eosinophilia (15-30%)
CNS tumors
Bone tumors
Ddx: osteomyelitis,
eosinophilic granuloma
(langerhans cell
Undifferentiated sarcoma that histiocytosis),
arises primarily in bone osteosarcoma,
- t(11;22) in 85% of pts neuroblastoma or
Pain and localized swelling Chemo + radiation
– adolescents rhabdomyosarcoma
Ewing sarcoma Systemic: fever, weight loss, fatigue - chemo: reduce size and treat mets
- flat and long bones: femur metastasis to bone
(almost all pts have mets)
(20%), pelvis (20%), fibula (12%),
humurs and tibia (12%) Radiographs: lytic bone
- begins midshaft in long bones lesion with calcified
periosteal elevation
(onion skin) and/or soft
tissue mass
Diagnostic evaluation:
- IgG, IgA, IgM levels
X linked agammaglobulinemia - serum protein screen - albumin or
(Bruton): no mature B cells. Life transferrin to r/o other etiologies
threatening enterovirus infections - antibody titers after immunization
(tetanus and diptheria = protein
CVID: hypogammaglobulinemia, antigens; pneumococci and H
Humoral immunity:
esp IgG and IgA. Decr antibody Recurrent infections with encapsulated organisms influenza = carb antigens)
Antibody deficiency IVIG
formation to vaccines. Incr after 6 mos- otitis media, sinusitis, pneumonia
syndromes
lymphoma and autoimmune dz Transient
hypogammaglobulinemia of
Selective IgA deficiency: IgA <5 infancy: delayed acquisition of
mg/dl, bacterial infections of normal infant immunoglobulin levels
respiratory, GI, and urinary tracts - most develop normal levels by 2-5
yrs, have intact responses to
vaccination
Ddx:
- Food intolerance: nonimmunologic Avoid offending food
80% present in 1st year (caffeine-induced tachycardia, - Cow milk, egg, soy, and wheat
Isolated cutaneous rxns, GI sxs, respiratory sxs,
Food allergies - peanuts, eggs, milk, soy, wheat, lactose intolerance) allergies can be outgrown
life-threatening anaphylaxis.
tree nuts, fish - peanut, nut, and fish allergies
Double-blind placebo challenge - usually persist
food challenge: gold standard.
Rheumatology
MCC of hydronephrosis in
childhood
- Primary: intrinsic narrowing at Newborns: palpable abdominal
junction of renal pelvis and ureter mass
Ureteropelvic Surgical correction: minimally
or angulation of ureter from a Older children: abd or flank pain, Renal US
junction obstruction invasive surgery or open pyeloplasty
crossing renal vessl cyclic vomiting, hematuria +
- Secondary: scarring, angulation mass
secondary to ureteral dilation
(stones)
UTI
DDx:
- Adenovirus: self-limited
hemorrhagic cystitis that does not
respond to abx
- Posterior urethralgia: benign, self- Pts with positive leukocyte esterase
limiting inflammation of posterior should be treated for presumed UTI
Infants: fever may be only sign
urethra in boys until culture results are available
- hematogenous seeding of Pyelonephritis:
- Lower lobe PNA in febrile child:
First year of life: girls = boys kidney perinephric Bagged specimens are
f/chills/flank pain
UTI After first year: girls have 10x abscess, renal inadequate for UTI
- Urolithiasis: dysuria, hematuria, Cystitis: amoxicillin, ampicillin,
incidence Older children: same as in adults scarring, renal evaluation
flank pain nitrofurantoin, or TMP-SMX
- upper tract involvement: incr failure
WBC, ESR, CRP
All children <24 months must Pyelonephritis: PO cephalosporin or
undergo renal US to r/o IV ampicillin + gentamicin
hydronephrosis or structural lesions.
VCUG if hydronephrosis or
nonresponders to abx. DMSA if
suspected pyelonephrosis
4% of children
Esotropia: inward
Amblyopia,
Exotropia: outward Amblyopia found in most pts with Corrective lenses, occlusion,
Strabismus Corneal light reflex, cover test reduced
Associated with cerebral palsy, esotropia atropine penalization, surgery
stereopsis
down syndrome, hydrocephalus,
brain tumors